Item C33
BOARD OF COUNTY COMMISSIONERS
~~-
Louis LaTorre
Senior Director
Social Services
LT/tabt
Revised 2/95
AGENDA ITEM SUMMARY
MEETING DATE: 2/16-17/2000
DIVISION: COMMUNITY SERVICES
BULK ITEM: YES X
NO
DEPARTMENT: SOCIAL SERVICES
AGENDA ITEM WORDING: APPROVAL OF AMENDMENT 002 TO JULY 1, 1999 THRU JUNE
30,2000 HOME AND COMMUNITY BASED MEDICAID WAIVER CONTRACT #KSOOI2
BETWEEN THE ALLIANCE FOR AGING, INC. , THE AREA AGENCY ON AGING FOR
PLANNING AND SERVICES AREA 11 AND MONROE COUNTY BOARD OF COUNTY
COMMISSIONERS/ MONROE COUNTY SOCIAL SERVICES (MONROE COUNTY IN HOME
SERVICE PROGRAM, THE CASE MANAGEMENT AGENCY).
ITEM BACKGROUND: This amendment is to authorize the Third Quarter Spending Authority of
$38,201.00, which will increase the total contract dollar amount to $114,603.00.
PREVIOUS RELEVANT BOCC ACTION:
Approved
STAFF RECOMMENDATION: APPROVAL
TOTAL COST: $114,603.00
BUDGETED: YES
NO X
--
COST TO COUNTY: $-0-
REVENUE PRODUCING: N/A YES_ NOx.. AMT.PER MONTH
YEAR
APPROVED BY: COUNTY ATTY....x.. 0
ENT ...x
DIVISION DIRECTOR APPROVAL:
DOCUMENTATION: INCLUDE
DISPOSITION:
TO FOLLOW__ NJ~
AGENDA ITEM#:
AGENDA.DOC
TABT
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract #KSOOI2 AMENDMENT 002
Contract with:Alliance For Aging. Inc. Effective Date:July 1. 1999
Expiration Date:June 30, 2000
Contract Purpose/Description:Approval of Amendment 002 to Home and Community Based
Medicaid Waiver Contract to authorize the Third Quarter Spending Authority of$38,201.00,
which will increase the total contract dollar amount to $114,603.00.
I
Contract Manager: Louis La Torre/tabt ~,~
(N ame) C Ll (Ext.)
Social Services
(Department)
for BOCC meeting on 2/16-1712000
Agenda Deadline: 2/2/2000
CONTRACT COSTS
Total Dollar Value of Contract: $114.603.00 Current Year Portion: $N/A
Budgeted? YesD No [g] Account Codes: _-_-_-_
Grant: $114,603.00 NA-_-_-_
County Match: $N/A NA-_-_-_
NA-_-_-_
ADDITIONAL COSTS
Estimated Ongoing Costs: $_/yr For:
(Not included in dollar value above) (eg. maintenance, utilities, ianitorial, salaries, etc.)
CONTRACT REVIEW
Changes. . ~ Date Out
Needed Re . lA !r, rI
YesD No . ~. t UYOo
~! JU
O. .B.lPur~~hsmg 1/31/&:> YesD No0' 9llI.A rJ:t(/~
County Attorney "2 -"3 CO~ YesD NO~
Comments:
Date In
Division Director
. 1, 3 \\\oc:.,
~
,
? ... t.{ - C<J)
OMB Form Revised 9/11/95 Mep #2
AMENDMENT tHill2.
Spending Authority Contract #KSOOI2
Page 1
THIS AMENDMENT, entered into between the Alliance for Aging, hereafter
referred to as the "Alliance", and Monroe County Social Services, hereinafter referred to
as the "case management agency", amends spending authority contract #KSOOI2.
The purpose of this amendment is to increase the Home and Community Based Medicaid
Waiver spending authority by $ 38.201, for the State Fiscal Year 1999-2000.
1. Section II is hereby amended to read:
II. The Alliance Agrees:
Spending Authority
The Alliance authorizes payment in accordance with Attachment 1 to this
agreement in the amount of $ 114.603 for the Home and Community Based
Medicaid Waiver for SFY 99-00. Authorized spending authority contract
allocation to date are as follows:
Quarter Dates HCBS
First 6/01 - 9/30/99 25,467.33
Second 10/1 - 12/31/99 50,934.67
Third 1/01 - 3/31/00 38,201
Fourth 4/01 - 6/30/00 0
TOTAL 114,603
The Case Management agency must not exceed allocated spending authority limits
without first obtaining written authorization from the Alliance. The Alliance is
responsible for continued monitoring of Case Management agencies to facilitate
compliance with this requirement.
This amendment shall begin on the date on which the amendment has been signed by
both parties.
All provisions in the spending authority contract and any of its attachments which may be
in conflict with this AMENDMENT are hereby changed to conform with this
AMENDMENT. All provisions not in conflict with this AMENDMENT are still in
effect, and are to be performed at the level specified in the contract.
This AMENDMENT and all its attachment are hereby a part of the contract.
AMENDMENT #002
Spending Authority Contract #KS0012
Page 2
IN WITNESS THEREOF, the parties hereto have caused this2 page AMENDMENT to
be executed by their undersigned officials as duly authorized.
CASE MANAGEMENT AGENCY:
MONROE COUNTY SOCIAL SERVICES
AREA AGENCY ON AGING:
ALLIANCE FOR AGING, Inc.
SIGNED
BY:
SIGNED
BY:
NAME:
NAME:
Martin Urra
TITLE:
TITLE:
Board President
DATE:
DATE:
B
M1END~NT tillQl
Spending Authority Contract #KSOO 12
Page 1
. .
TillS AMENDMENT, entered into between the Area Agency on Aging Inc., Alliance for
Aging, hereafter referred to as the "Alliance", and Monroe County Social Services, hereinafter
referred to as the "case management agency", amends spending authority contract #KSOO 12.
The purpose of this amendment is to increase the Home and Community Based Medicaid Waiver
spending authority by $ 50.934.67, for the State Fiscal Year 1999-2000.
1. Section II is hereby amended to read:
II. The Alliance Agrees:
Spending Authority
The Alliance authorizes payment in accordance with Attachment 1 to this agreement in
the amount of $ 76.402 for the Home and Community Based Medicaid Waiver for SFY
99-00. Authorized spending authority contract allocation to date are as follows:
Quarter Dates HCBS
First 6/01 - 9/30/99 25,467.33
Second 10/1 - 12/31/99 50,934.67
Third 1/01 - 3/31/00 0
Fourth 4/01 - 6/30/00 0
TOTAL 76,402
. The Case Management agency must not exceed allocated spending authority limits
without first obtaining written authorization from the Alliance. The Alliance is responsible for
- continued monitoring of Case Management agencies to facilitate compliance with this
requirement.
This amendment shall begin on the date on which the amendment has been signed by both
parties.
All provisions in the spending authority contract and any of its attachments which may be in
conflict with this AMENDMENT are hereby changed to conform with this AMENDMENT. All
provisions not in conflict with this AMENDMENT are still in effect, and are to be performed at
the level specified in the contract.
This AMENDMENT and all its attachment are hereby a part of the contract.
M1ENDl'AENT iEillll
Spending Authority Contract #KSOO 12
Page 2
. .
IN WITNESS THEREOF, the parties hereto have caused this.2 page AMENDMENT to be
executed by their undersigned officials as duly authorized.
CASE MANAGEMENT AGENCY:
MONROE COUNTY SOCIAL SERVICES
ALLIANCE:
ALLIANCE FOR AGING, Inc.
SIGNED
BY:
. SIGNED
BY:
NAME:.
NAME: Ramona Frischman. Ed. D.
TITLE:
TITLE: Board President
DATE:
DATE:
- t
Contract No. KS0012
Medicaid Waiver SpendUq: Authority Coatrad
Case Managemmt Agency
.'
Monroe County In-Home Social Services
(Case Management.fgency Namt!J
TIllS CONTRACT is entered into between the Alliance for Aging, -hereinafter- referred-to as the
"Alliance", and the Monroe County In-Home Social Services, hereinafter referred to as the "case management
agency:. _
The -parties agree:
I. The. Case Management Agency Agrees:
A. Services to be Provided
To plan, develop, and accomplish the services delineated, or otherwise cause the planning,
- development, and accomplishment of such services and activities, under the conditions specified
and in the manner prescribed in Attachment..!. of this agreement.
B. Request for Payment
Service provider agencies should sUbmit requests for payment (claims) to the Mewcaid fiscal agent
within --.QQ days after services have been provided or document reasons for delayed submission of
claims which will be made available to the Case Management agency and Alliance upon request;
if the service provider fails to submit claims within~ days and fails to document reasons for
delayed submission as required, spending authority amounts may be adjusted to reflect the
most current claim (expenditure) informatiOll available. Future allocations amounts may be
contingent on timely submission of claims.
C. Conflict of Interest
The case management agency hereby agrees that it will develop and implement a policy to ensure
that its employees, board members, manageme~ and service providers, will avoid any conflict of
interest o!" the appearance of a conflict of interest when disbursing or using the funds described in
this agreement or when contracting with another entity which will be paid by the funds described
in this agreement. A conflict of interest inciudes, but is not limited to, receiving, or agreeing to
receive, a direct or indirect benefit, or anything of value from a service provider~ client, vendor,
or any person wishing to benefit from the use or disbursement of funds. To avoid a conflict of
interest, the case management agency must ensure that all individuals make a disclosure to the
Alliance of any relationship which may be a conflict of interest, within thirty (30) days of an
individual's original appointment or placement on a board, or if the individual is serving as an
incumbent, within thirty (30) days of the commencement of the contract.
D. Audits and Records
1: To maintain books, records, and documents (mc1uding electronic storage media) in accordance
1
Contract No. KS0012
with generally accepted accounting procedures and practices which silfficiently and properly
reflect all revenues and expendin.Jres of funds provided by the Alliance under all contracts under
this agreement.
2. To assure these records shall be subject at all reasonable times to inspection, review, audit,
copy, or removal from premises by Alliance, state personnel and other personnel duly
authorized by the Department of Elder Affairs, as well as by federal personnel, if applicable.
. 3. To maintain and file with the Alliance such progress, fiscal and mventory and other reports as
the Alliance may require Within the period of this agreement. Such reporting requirements must
be reasonable given the scope and purpose of the contracts incorporating this agreement by
reference.
4. To include these aforementioned audit and record keeping requirements in all approved
agreements and assignments.
.5. The case management agency agrees to respond to requests for client information and statistical
data for research and evaluative purposes when requested by the Alliance.
E. Monitoring _
I. To provide progress reports, mcluding data reporting requirements as specified by the Alliance.
These reports will be used for monitoring progress or performance of the contractual services
as specified in this agreement.
2. The case management agency agrees to coordinate meetings with the service providers as
requested by the Alliance when it becomes evident that spending authority amounts are not
being properly managed in accordance with this agreement.
3. To permit persons duly authorized by the Alliance to inspect any records, papers, documents,
facilities, goods and services of the provider which are relevant to this agreement or the mission
and statutory authority of the department, and/or interview any clients and employees of the
case management agency to be assured of satisfactory performance of the terms and conditions
of the contract. Following such inspection the Alliance will deliver to the case management
agency a list of its concerns with regard to the manner in which said goods or services are
being provided. The case management agency will rectify all noted deficiencies provided by
the Alliance within the time set forth by the Alliance, or provide the department with a
reasonable and acceptable justification for the provider's failure to correct the noted
shortcomings. The Alliance shall determine whether such failure is reasonable and acceptable.
The case management agency's failure to correct or justify deficiencies within a reasonable time
as specified by the Alliance may result in the Alliance taking any of the actions identified in the
Enforcement section, or the Alliance deeming the case management agency's failure to be a
breach of contract.
2
Contra~No. KSOOi2
ll. The Alliance Agrees:
Spending Authority
The Alliance authorizes payment in accordance with Attachment I to this agreement hr'the amount of
$ 25.467.33 for the Home and Community Based Medicaid Waiver for the first quarter of SFY 99-00.
Case Manaiement aiencies must not exceed allocated spendini authority limits without first obtaining
written authorization from the Alliance. Case Management agency is _ responsible for continued
- monitoring of service providers to -facilitate compliance with this requirement.
ID. The Case Management Agency and Alliance Mutually Agree:
A. 'Effective Date
1. This contract shall begin on July I. 1999
by both parties, whichever is later.
or on the date the contract has been signed
2. This-contract shall end on
June 30.2000
B. Termination
1. Termination at Will
This agreement may be terminated by either party upon no less than thirty (30) calendar days
notice, without cause, unless a lesser time is mutually agreed upon by both parties, in writing.
Said notice shall be delivered by certified mail, return receipt requested, or in person with proof
of delivery. -
2. Termination Because of Lack of Funds
In the event funds to finanCe this agreement become unavailable, the Alliance may terminate
this agreement upon no less than twenty-four (24) hours notice in writing to the case
- management agency. Said notice shall be delivered by certified mail, return receipt requested,
or in person with proof of delivery. The Alliance shall be the final authority as to the
availability of funds.
3. Termination for Breach
Unless the case management agency's breach is waived by the Alliance in writing, or the case
management agency fails to cure the breach within the time specified by the Alliance, the
Alliance may, by written notice to the case management agency, terminate this agreement upon
no less than twenty-four (24) hours notice. Said notice shall be delivered by certified mail,
return receipt requested, or in person with proof of delivery. If applicable, the Alliance may
employ the default provisions in Chapter 60A-1.006(3), Florida Administrative Code. The
provisions herein do not limit the Alliance's right to remedies at law or to damages.
3
Contract No. KSOO12
4. The provisions herein do not limit the AlliaIn's right to - remedies at law or to damages, or to
legal remedies of an equitable nature. If the Alliance engages any of the enforcement provisions
contained in part C below, the Alliance may in its sole discretion determine if the termination
of the contract is Warranted. _ _
c. Enforcement
The Alliance may in accordance with section 430.04, Florida Statutes, rescind designation of the
case management agency as a provider agency, or take immediate action against the case
. management agency, including corrective action, unannounced special monitoring, temporary
assumption of the operation of one or more programs, placement of the case management agency
on probationary stams, iinposing a moratorium on case management agency action, imposing
financial penalties for non performance, or other administrative action pursuant to Chapter 120
_Florida Statutes, if the Alliance finds that:
· An intentional or negligent act of the case management agency has materially affected the
health, welfare, or safety of clients, or substantialIy and negatively affected the operation of an
aging services program.
· The case management agency lacks financial stability sufficient to meet contractual obligations
or that contractual funds have _been misappropriated.
· The case management agency has committed multiple or repeated violations of legal and
regulatory standards, regardless of whether such laws or regulations are enforced by the
Alliance, or the case management agency has committed repeated violations of Department of
Elder Affairs standards.
· The case management agency has failed to conrinue the provision or expansion of services after
the declaration of a state of emergency.
· - The case management agency has failed to adhere to the terms of its contract with the Alliance.
In -making any determination under this provision, the Alliance may rely upon the findings of another
state or federal agency. or other regulatory body. Any claim for breach of this contract is exempt from
administrative proceedings and shall be brought to the venue of Miami-Dade County in the appropriate
court. Before the Alliance formally rescinds the designation of the case management agency, initiates
any intermediate measure, or either party commences equitable or legal action of any sort, both parties
agree to engage in informal mediation through a meeting of each party's representatives at a place and
location designated by the Alliance.
D. Notice and Contact Information
1. The name, address, and telephone number of the contract manager for the Alliance for this
contra~t is:
4
Contract No. KS0012
John L. Stokesbeny
Alliance for Aging
9500 South Dadelami Blvd., Suite 400
Miami, Florida 33156
(305) 670-6500
2. The name, address, and telephone number of the representative of the case management agency
responsible for administration of the program under~s contact is:
Louis LaTorre -
5100 Collqe Road
Key West. FL 33040
(305) 292-4572
3. In the event different representatives are designated by either party after execution of this
contract, notice of the name and address of the new representative will be rendered in writing
to the other party and said notification attlched to originals of this contract.
5
. i
Contract No. KS0012
IN WITNESS THEREOF, the parties hereto have caused this -1L page contract to be executed by
their. undersigned officials as duly authorized.
CASE MANAGEMENT AGENCY:
Monroe County In-Home Social Services
Alliance:
Alliance for Aging
Board President or Authorized Designee
Board President or Authorized Designee
SIGNED_~..._ .. ,....,....., _._.~...
~."'~~ ~P~"V'o-' <..- .\ '\ .. .
BY: '-... - -i'
NAME:' {AJ/ L...Ik-Ll-'1lrv~V€. V
TITLE: M A- t.f~ C
DATE: 7 -.;2. / - 99
FEDERAL ID NUMB~R: 65-0101947
PROVIDER FISCA1YEAR END DATE: 9/30
/.:.<:ij;~~;L'~~'. .
<"~":"'l" (SEAL}' .
"'-'/--' _ ~!r~M':J)ANNY L I<OlHAGE, QERI<
", .:,~;jioYjk~ c. A2a0~
\~ .,' '-::.",,-,,'::-~ DEPUTY CLERK /
";;"'.; ~. I ./'~:.
'.. ..'~- ,..--'
SIGNED
BY: --r?<lSn\crn c\ 2\\ \J',~
NAME: Ramona Frischman Ed.D.
TITLE: _Board President
DATE: <6 f ~ I q q
6
3AfYJ PLE
Contract No. KSOO12
AITACHMENTI
HOME AND COMl\fiJNITy BASED WAIVER
REFERRAL AGREEMENT
This Referral Agreement, made this _ day of _, 1999. shall be in effec~ for the period of
to between, Ihe Area Agency on Aging for PIanning
and Service Area _; , the case management ageucy; and , the Service
Provider Agency. The purpose of this agreement is to promote thC.deveIopment of a coordinated service
delivery system to meet the needs of the aged or disabled 3dutts who are at risk of premature
instittitionalization.
I. Objectives
1. To maintain a climate of cooperation and consultation with and between agencies, in order to
achieve maximum efficiency and effectiveness.
2. . .To Participate together by means of shared information in the development and expansion of
services.
3. To promote programs and activities designed to prevent the premature institutionalization of elders
and disabled adultS.
4. The parties of this Agreement will provide technical assistance and consultation to each other on
matters pertaining to actual service delivery and share appropriate assessment information and
care plans so duplication may not occur.
n. Under this Agr~ent, the Service Provider Agency agrees to the following:
1. To accept referrals for the 1915c Home and Community Based Service (HCBS) Medicaid Waiver
from only the above designated case management agency.
2.' To provide quality service(s) specified in Section V to the waiver participant. Provision of
service(st is subject to quality monitoring and/or observation by the case management agency
and/or the Area AgenCy on Aging. -
3. To provide only those services specifically outlined in the Plan of Care or service authorization
submitted by the above designated case management agency.
4. To attach documentation regarding provider qualifications. to this agreement; and to provide, as
requested, any information regarding Medicaid Waiver billing, payment, or waiver participant
information, to the Case Management Agency or Area Agency on Aging. Provider rate
increases/decreases must be forwarded to the Case Management Agency and Area Agency on
Aging along with justification for any increase. If additional services are to be added to this
7
Contract No. KS0012
agreement, a written request to do so must be received by the Area Agency on Aging and an
amendment must be prepared by the Area Agency on Aging listing the added service(s). The
necessary documentation regarding provider qualifications for the additional s.e~ces will be
signed, attached to the agreement and forwarded to Ihe Area Agency on Aging. - -
5. To maintain the waiver participant's confidentiality according to 42 CFR 431.301.
6. To immediately report any changes in the waiver participant's condition to the designated Case
Management Agency.
7. To maintain enrolled provide'r status by renewing applicable licensure, certification, contract,
and/or referral agreements.
8. Include its name, unit rate, and other appropriate information on a list of all enrolled providers
-' which will be shown to recipient during development of an individualized plan of care
understanding that the recipient reserves the right at all times to a choice of enrolled providers.
9. - To immediately notify the Case Management Agency of staffing shortfalls which will negatively
impact provision of service to Medicaid Waiver recipients.
10. To submit claim. data for billing to the Medicaid fiscal agent within 60 days after services have
been provided or document reasons for delayed submission of claims. Such documentation shall
be available for review by the area agency on agency or by. the Department of EIder Affairs, upon
request.
11. To submit claims for billing to the Medicaid fiscal agent at the agency's usual and customary rate.
It is a violation of federal regulation to bill Medicaid more than the agency's usual and customary
rate.
12. The service provide{ agency hereby agrees that it will develop and implement a policy to ensure
that its employees, board members, and management, will avoid any conflict of interest or the
appearance of a conflict of interest when disbursing or using the funds described in this agreement
or when contracting with- another entity which will be paid by the funds described in this
agreement. A conflict of interest includes, but is not limited to, receiving, or agreeing to receive,
a direct or indirect benefit, or anything of value from a service provider, client, vendor, or any
person wishing to benefit from the use or disbursement of funds. To avoid a conflict of interest,
the service provider agency must ensure that all individuals make a disclosure to the Area Agency
on Aging of any relationship which may be a conflict of interest, within thirty (30) days of an
individual's original appointment or placement on a board, or if the individual is serving as an
incumbent, within thirty (30) days of the commencement of the contract.
m. Under this Agreement, the Area Agency OD Aging agrees to the following:
8
1. To facilitate the enrollment of providers with the Medicaid FJSC3I Agent.
2. To provide technical assistance and training to Service Providers.
3. To determine that the case management agency is conducting monitoring of its service- Providers.
4. To regularly monitor the Service Providers in accordance with requirements specified by the Department
of Elder Affairs. -
Contract No. KS0012
IV. Under this Agreement, the Case Management Agency.agrees to the following:
1. The case management agency shall submit written referral to service provider agency with at least 24
hours notice. The case management agency may refer recipients to any qualified service provider
agency. The referral will contain, at a minimum:
a. Name
. . - b. Address (with directions if not easily accessible)
c. Pertment information regarding recipient's health or disabilities and living situation.
d. Detailed service authorization including frequency, duration, and.specific tasks to be performed.
. .
2. Maintain case records ii1 accordance with the Aged and Disabled Adult Medicaid Waiver Coverage and
Limitations Handbook.
3. Evaluate quality of services and service documentation as provided by service provider agency.
4. Accept financial responsibility for service claims found out of compliance if they are the result of a
failure by the Case Management Agency to update, renew, or terminate the service authorization.
5. To monitor service provider agencies billings to ensure spending is within allocated spending limits.
6. To monitor service provider agencies for adherence to authorized case plans and with in authorized
rates.
7. The case management agency hereby agrees that it will develop and implement a policy to ensure that
its employees, board mem~rs, and management, will avoid any conflict of interest or the appearance
- of a conflict of interest when disbursing or using the funds described in this agreement or when
contracting with another entity which will be paid by the funds described in this agreement. A conflict
of interest includes, but is not limited to, receiving, or agreeing to receive, a direct or indirect benefit,
9r anything of value from a service provider, client, vendor, or any person wishing to benefit from the
use or disbursement of funds. To avoid a conflict of interest, the case management agency must ensure
that all individUals make a disclosure to the Area Agency on Aging of any relationship which may be
- a conflict of interest, within thirty (30) days of an individual's original appointment or placement on a
board, or if the individual is serving as an incumbent, within thirty (30) days of the commencement of
the contract. :
9
Contract No. KS0012
v. Under this agreement, the following services will be delivered by the Service Provider Agency in
accordance with the plan of care or service authorization: . .
Service Unit Rate CountylRegion Served
l.
2.
3,
4.
5.
VI. Termination
In the .event this agreement is terminated, the case management agency and the service provider agency
agree to- submit, at the time notice of intent to terminate is delivered, a plan which identifies procedures to
ensure services to clients will not be interrupted or suspended by the termination.
1. Termination at Will
This agreement may be terminated by any party upon no less than thirty (30) calendar days notice,
without cause, unless a lesser time is- mutually agreed upon. by both parties, in writing. Said notice
shall be delivered by certified mail, return receipt requested, or in person with proof of delivery.
2. Termination Because of Lack of Funds
In the event funds to finance this agreement become unavailable, the area agency may terminate
this agreement upon no less than twenty-four (24) hours notice in writing to the other party. Said
notice shall be delivered by certified mail, return receipt requested, or in person with proof of
delivery. The area agency shall be the final authority as to the availability of funds.
- 3.. Termination for Breach
Unless a breach is waived by the area agency in writing, or the parties fail to cure the breach
within the time specified by the area agency, the area agency may, by written notice to the parties,
terminate the agreement upon no less than twenty-four (24) hours notice. Said notice shall be
delivered by certified mail, return receipt requested, or in person with proof of delivery .
10
Contract No. KSOO12
VIT. In witness whereof, the parties have caused this _ page agreement to be executed by their
undersigned officials as duly authorized. - - _.-
Case Management Agency
Service Provider Agency
r sillWlUe
sigaalUre
print name
prim name
title
Iide
dale
cIatc
- Area Agency on Aging
Signature
Print
Title
Date
11