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State of North Carolina <br />Division of Social Services <br />Contract Application Page 6 of 8 <br />( ) 2. The provider certifies through the contract budget attached to <br />this contract that the matching share is available. Further, <br />it is agreed that the provider will report all program costs <br />incurred each month relating to this contract on the DSS -1571. <br />However, reimbursement will be limited to the federal /state <br />financial participation rate. <br />(X) 3. The county department of social services is providing the match. <br />G. Provider Fees (For Purchase Contracts Only) <br />( ) <br />I. The Provider agrees to pay the Department /Division up to $ _ <br />Administrative Fee as payment in full for the administration of the <br />contract. The amount of the fee is five percent of the matching <br />share contributed by the Provider. <br />( ) 2. The Provider agrees to pay the Department up to �� Certifica- <br />tion Fee as payment in full for the determination and certification <br />of client eligibility. The amount of the fee is five percent - <br />of the matching share contributed by the Provider. <br />Monitoring and Certification Fees, when applicable, will be deducted <br />from the amount to be reimbursed. <br />*N /A Provider match contributed by Orange County DSS <br />DSS -1292 (4/87) <br />Family Services <br />