HCCBG FY14 FINAL FUNDING PLAN 2CD
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NAME AND ADDRESS
Home and Community Care Block Grant for Older Adults
COMMUNITY SERVICE
PROVIDER
DOA-732 (Rev. 4/14)
County Funding Plan
County_ 'New HanoN er
Elderhaus, Inc.
July 1, 2013 through June 3, 2014
1950 Amphiteater Dr.
Provider Services Summary
REVISION L3, DATE 7/14
Wilmington, NC 28401
A
B C
D
E
F
H T- I
Ser. DelNery
i Projected Projected
Projected Projected
(Check One)
Block Grant Funding Required Net*
NSIP
Total
HCCBG Reimburse.
HCCBG Total
Services
Direct IPurch.
Access
In -Home
Other
Total Local h latcE Sery Cost
Subsidy
Funding
Units Rate
Clients Units
Adult Day Care
64705
111111111111111111 7189 X894 894
71894
1135 633395
1
Adult Day Health
35337
—
3926 39263
39263
559 701497
Transportation- ADC
735
IIIIIt111111111111 82 817
917
5451 1.50
Transportation- ADH
495
11i11111110tt1tt11 i55 550
550
367 1.50
0 0
0
0 0
0
0 0
0
0 0
0
0 0
0
0 0
0
0 0
0
0 0
0
0 0
0
0 0
0
Total
0
100042
1230
101272 11252TI12524
0
112524
2605.29754 1111111titt111
0 0
*Adult Day Care & Adult
Day Health Care Net Service Cost
ADC riDHC
Daily Care
33.07
40.00
Certification of required minimum local match availability.
Transportation
Required local match will be expended simultaneously
Atit-horized. Signature, Title Date
Administrative
Net Ser. Cost Total
30.27
30.24
with Block Grant Funding.
Corn Service Pro ' &r A
7
63.34
10.24
Signature, County Finance Officer Date
Signature, Chairman, Board of Commiss`to /–ers Date
NAME AND ADDRESS Home and Community Care Block Grant for Older Adults
COMMUNITY SERVICE PROVIDER DOA -732 (Rev. 2110)
Interim Healthcare of the Eastern Carolinas, Inc. County Funding Plan County New Hanover
PO Box 2249 July 1, 2013 through June 30, 2014
Whiteville, NC 28472 -7249 Provider Services Summary IREVISION#3 , DATE :07/17114
A
B
C
D
E
F
G
H
I
Projected
Projected
Projected
Projected
Ser. Delivery
(Check Ooe) Block Grant Funding
Required
Net,`
NSIP
Total
HCCBG
Reimburse
HCCBG
Total
Direct
1purch,
Access
In -Home
Other
Total
Services
Local Ibiatch
Sery Cost
Subsidy
Funding
Units
Rate
Clients
Units
IHA Level I
X
18044
111111111111111111
2005
20054
20054
1 1203
16.6672
6
1203
IHA Level 2
X
89272
11111111111111111
9919
99191
99191
5853
16.9464
30
5853
IHA Level 3
X
58808
111111111111111111
6534
65342
65342
3813
17.1366
IS
3807
111111111111111111
0
0
0
111111111111111111
0
0
0
111111111111111111
0
0
0
11111111111111111
0
0
0
luuullu���u��
0
0
0
111111111uuu111
0
0
0
111111111111111111
0
0
0
111111111111111111
0
0
0
111111111111111111
0
0
0
111111111111111111
0
0
0
111111111111111111
0
0
0
Total
11111111111111
0 1
1661291
0
166129
I8458
184587
0
184587
1086911111111111111
51
10863
"Adult Day Care & Adult Day Health Care Net Senice Cost
ADC ADHC
Daily Care _ Certification of required minimum local match a` ailability.
,e
Transportation Required local match will be expended simultaneously Auth rized Signature. Ti Date
Administrative with Block Grant Funding. C unify i Provider
Net Ser. Cost Total '1
• P°
Signature, County Finance Officer Date Signature, Chairman, Board of Commissioners Date