Area(s) of Service Coverage: (i.e., counties, townships, etc.) The above-named agency declares the following unit rates for National Family Caregiver Support services for FY2017-2018: Personal Care/Respite: $ /hour Adult Day Service: $ /day Are you currently providing this service(s)? Yes No If yes, check all applicable funding sources: PASSPORT Private Pay National Family Caregiver Support Other: Medicaid Other: Name and Title of Person Completing Application: Signature: Date: EXHIBIT B-1 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION PURSUANT TO 45 CFR PART 76 LOWER TIER TRANSACTIONS (Name of Agency or Organization) certifies by submission of this proposal that neither it or its principles is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency. Where the agency is unable to verify any of the statements in this certification, such agency shall attach an explanation to this proposal. Signature of Authorized Individual
Area(s) of Service Coverage: (i.e., counties, townships, etc.) The above-named agency declares the following unit rates for National Family Caregiver Support services for FY2017-2018: Personal Care/Respite: $ /hour Adult Day Service: $ /day Are you currently providing this service(s)? Yes No If yes, check all applicable funding sources: PASSPORT Private Pay National Family Caregiver Support Other: Medicaid Other: Name and Title of Person Completing Application: Signature: Date: EXHIBIT B-1 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION PURSUANT TO 45 CFR PART 76 LOWER TIER TRANSACTIONS (Name of Agency or Organization) certifies by submission of this proposal that neither it or its principles is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency. Where the agency is unable to verify any of the statements in this certification, such agency shall attach an explanation to this proposal. Signature of Authorized Individual
NFCSP%20Application%20Packet%202017-2018.docx