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PROVIDERIAAA CHECKLIST Countv Name Cabarrus FY15 F -5 Page 296 NOTES: Department of Human Services DATE: April 11, 2014 DATE Aging Funding Plan Draft Forms Submitted DOA -730 4/14/14 DOA -731 4/14/14 DOA -732 4/14/14 DOA -732A 4/14/14 DOA -732A1 4/14/14 DOA -733 4/14/14 DOA -734 4/14/14 C/P Rights 4/14/14 Budget Analysis Matches DOA -732 DOA -732 Grant Funds for FY'2015 = 433206 433206 4114/14 DOA 732a Revenues - Line I.J = 709355 4/14/14 DOA 732a Expenses - Line II.J 804180 4/14/14 Revenues Line III. A. I = 804180 4/14/14 Expenses Line 111.6.1 709355 4/14/14 Revenues Match Line I.J = 709355 4/14/14 Revenues Line 111.6.1 709355 4/14/14 Expenses Match Line II.J = 804180 4/14/14 Expenses Line III.A.1 804180 4/14/14 DOA -732a1 Total = 205728 4/14/14 DOA732a Line ILA 205728 4/14/14 USDA correct for total service units @ 0.75 #REF! 12419 12419 4/14/14 ADH service cost matches allowable rate Matches DOA732A DOA732 DOA732A DOA732 Block Grant Funding Line LA Col. A Total 433206 433206 Required Local Match -Cash & In -Kind Line 1.13 Col. B Total 48134 48134 Net Service Cost Line LC Col. C Total 481340 481340 USDA Subsid Line I.D Col. D Total 12419 12419 Total Funding Line I.0 +I.D Col. E Total 493759 493759 Projected HCCBG Reimbursed Units Line III.0 -Total Col. F Total #DIV /0! \ \ \ \ \ \ \ \ \ \ \ \ \\ Total Reimbursement Rate Line 111.6.5 (by Service Col. G (by Service Projected Total Service Units Line III.F Total Col. I Total #DIV /0! #DIV /0! F -5 Page 296