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<br />PROVIDER CHECKLIST FOR HCCBG FUNDING <br /> <br />Service Providers are to complete and submit this checklist, along with completed forms. <br />Please use the following address: <br /> <br />CPRC AAA <br />Attn: Jenisha Henneghan <br />4307 Emperor Blvd., Suite 110 <br />Durham, NC 27703 <br /> jhenneghan@centralpinesnc.gov, 919.558.2708 <br /> <br />CPRC Form, Revised July 2023 <br />Provider Name: ____________________________________________________________________ <br /> <br /> DAAS-730 Lead Agency Only: Lead Responsibility for County Funding Plan <br /> <br /> DAAS-731 Lead Agency Only: County Services Summary <br /> <br /> DAAS-732 Provider Services Summary <br /> <br /> DAAS-732-A Service Cost Computation Worksheet (supports development of DAAS-732) <br /> <br /> DAAS-732-A1 Labor Distribution Schedule <br /> <br /> TJCOG AAA Form Certification of Required Minimum Local Match Availability <br /> <br /> 732 In Home <br />Supplement <br /> <br />In-Home Aide Providers Only: In-Home Aide Supplement <br /> DAAS-733 Provider Methodology to Address Service Needs of Low Income, Rural <br />Elderly and Elderly with Limited English Proficiency <br /> <br /> DAAS-734 Community Service Provider Standard Assurances <br /> <br /> In-Home <br />Assurance <br />In-Home, Housing & Home Improvement, Adult Day or Day Health <br />Providers Only: Standard Assurance to Comply with OAA Requirements <br />Regarding Client Rights <br /> <br /> Exhibit 14-A and <br />Subcontract <br />Copies <br /> <br />List of Subcontractors (Exhibit 14A) and subcontracts (or MOA between <br />county departments, if applicable) <br /> <br /> <br />Total Allocation: _Use FY25 Total Allocation___ <br /> <br />The County Funding Plan is based on a 12-month funding cycle from July 1 through June 30. Most <br />forms listed above can be found at http://www.ncdhhs.gov/aging/cobudget/cobudgdn.htm <br /> <br />ORANGE COUNTY <br />4 <br />4 <br />4 <br />4 <br />4 <br />4 <br />4 <br />4 <br />4 <br />4 <br />Docusign Envelope ID: 33187FF3-2913-4BF6-A737-FFB28C0A4B95