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APPENDIX G <br />r <br />I <br />Cabarrus County Department of Human Services <br />PROVIDER ASSURANCE FORM <br />This is to certify that the opportunity to voluntarily contribute to the cost of services received has been <br />discussed with <br />(Client Name) <br />The discussion included informing the client or designated representative: <br />That the contribution is entirely voluntary and that there is no obligation to contribute. <br />That all contributions collected will be used to expand the service(s). <br />That information about the client's participation in consumer contributions shall be confidential. <br />That the client or designated representative should contact Cabarrus County Human Services at 704- <br />920 -1400 if there are questions regarding consumer contributions. <br />The total actual cost of the service(s). <br />That services will not be reduced or terminated for failure to contribute. <br />The process by which contributions will be collected should they decide to contribute. <br />APPLICABLE SERVICES <br />ACTUALCOST <br />Per Unit <br />In -Home Aide II- Personal Care <br />$15.29 per hour <br />In -Home Aide III — Personal Care <br />$15.30 per hour <br />Name <br />(Agency Representative Signature) <br />Date: <br />PLEASE SEND CONTRIBUTIONS TO <br />Cabarrus County Department of Human Services <br />1303 S. Cannon Blvd. Kannapolis, NC 28083 <br />704 - 920 -1400 <br />(Please include the name of the program(s) to which you are contributing) <br />Attachment number 1 \n <br />F -3 Page 51 <br />