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10 <br />State of North Cazolina <br />Division of Social Services <br />Contract Application <br />Page .3 of 7 <br />II. Fiscal Provisions <br />A. Amount of Reimbursement: <br />Reimbursement under the terms of this agreement will be limited to a maximum of: <br />$ 20,000 TOTAL = $ SSBG + $ IV-B + $ RAP + <br />State +$ County + $ <br />(Optional: County funds consist of $ for <br />for ) <br />Other (identify): TANF Block Grant <br />(funding source) <br />B. Method of Reimbursement: <br />1, For Purchase Contract (DSS-2497) Total and Unit Cost: <br />and$ <br />(X) a, Reimbursement will be made in accordance with the current budget approved by <br />the Department and on file with both pazties. The amount of reimbursement will be <br />based on allowable expenditures made in behalf of eligible clients, determined in an <br />accordance with acceptable cost allocation methods. The Provider will report all <br />expenditures made under the terms of the contract, <br />() b, Reimbursement will be made at a unit cost rate of $ per unit of <br />reimbursement delivered to eligible clients for an estimated number of _ <br />units, The Provider will document total expenditures made under the terms of the <br />contract to the Department within thirty days after the termination of this contract, <br />or as instructed by the Depaztment, Reimbursement which exceeds actual allowable <br />cost will be adjusted to actual allowable cost. <br />2. For Vendor Agreements (DSS-2252) Fixed Rate <br />Reimbursement will be based on: <br />O a, a standard fixed rate or <br />O b. an individual fixed rate. <br />c. Reimbursement will be made at a fixed rate of $ per unit of <br />(define) for as estimated number of units, <br />Reimbursement will be based on the actual number of units delivered whether over <br />or under the estimated number. If multiple components are being purchased, <br />additional rates and units can be identified as follows: <br />