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Application for Demonstration Project to Implement <br /> Consumer-Directed Care Service <br /> Face Sheet <br />Single Applicant Proposal Partnership Proposal <br /> <br />Name of Partner Agency(ies): Good Health Services, Inc. <br /> <br />X <br /> <br />Name of Lead Applicant Agency/Organization: <br /> <br />Federal Tax ID Number: 56-6000281 <br /> <br />Type of Applicant Agency/Organization: <br /> Public X Private <br /> <br />Name of Contact Person: Alta G. McKelvin <br /> <br />Job Title of Contact Person: Social Worker Supervisor II <br /> <br />Mailing Address: 1303 South Cannon Boulevard <br /> <br />Cabarrus County Dept. of Social Services <br /> <br />Private Non-Profit <br /> <br />(CAP Supervisor) :- , <br /> <br /> Karmapolis, NC 28083 <br /> <br />E-Mail Address: AmcKelvin(-~_,cabarrusdss.net <br /> <br />Telephone Number: (704) 920-1480 Fax Number: (704) <br />County(ies) to be served by the project: Cabarrus <br /> <br />Projected number of consumers to be served over 14-month period: ~ <br /> <br />Total amount of funds requested: $20,000 <br /> <br />Signature of individual who is authorized to legally bind the lead applicant <br />agency/organization, confirming their support of this proposal: <br /> <br />920-1577 <br /> <br />23 <br /> <br />Name: James F. Cook, Jr. Title: <br />Signature: Date: <br /> <br />Director <br /> <br />Please complete this page as presented. All of the information responding to the items on the following pages is to <br />be submitted in the order presented on separate pages with this Face Sheet on top. Submit the original and 10 copies <br />of the complete package. Please use only staples to bind each package together. Each package is to contain items in <br />the following order: <br /> Face Sheet <br /> Narrative Description of Items in I - V <br /> Budget Form <br /> Attachment A (timeline of activities) and Attachments B (if applicable) and C (letters of <br /> support, if provided) <br /> <br /> <br />