ࡱ> q` ;:bjbjqPqP 4::288T `K.( ( > > > > N Z     -I +J$FLhNJJb > > b b J> > J b d> >  b   >  \  d  J0K N* dN N b b b b b b b JJ Xb b b Kb b b b  10-144 DEPARTMENT OF HUMAN SERVICES OFFICE OF PLANNING, RESEARCH AND DEVELOPMENT Chapter 502: COMMUNITY HEALTH PROGRAM GRANTS POLICY MANUAL AND APPLICATION TABLE OF CONTENTS Page Chapter I Introduction 2 Chapter 2 Purpose of Manual 3 Chapter 3 Manual Structure 4 Chapter 4 Eligibility 5 Chapter 5 I. Selection Criteria 8 II. Grant Review Committee 10 Chapter 6 Process 11 Chapter 7 Comments and Appeal 12 Appendices Appendix A Application Instructions 13 Section 1 Program Description 14 Section 2 Budgetary and Financial Information 17 Appendix B Glossary of Health Care Terms 31 Appendix C Financial Glossary 37 and Auditing Standards Appendix D Agreements & Subcontracts 46 CHAPTER I - INTRODUCTION The Office of the Governor and State of fb88's One-Hundred & Fourteenth (114th) Legislature found that over 130,000 people in fb88 lacked health insurance. Considerably more people faced other barriers to access to health care. In an effort to meet this unmet need, the Governor an the Legislature designed programs to improve access to health care for persons who are currently inadequately cared for. The program which provides coverage of health care costs will lessen the burden on 3rd party payers of health care costs caused by bad debt and charity care. Consequently the Legislature passed and the Governor signed, 22 MRSA SS 3190 entitled Community Health Program Grants which became law on July 12, 1989. The Community Health Program was created to expand available health and medical resources to local community programs while encouraging development of efficient care for low-income persons.. The grants will be awarded to local health care providers or new organizations where existing providers are unwilling or unable to participate, who demonstrate the capacity to provide an organized system of primary care. Grants may be made for health promotion and health education programs when an applicant can demonstrate an ability to coordinate services and programmatic efforts with local primary care providers and provide a plan for follow-up care for their consumers. Grant awards will be for a one (1) year period. The legislature has authorized the awarding of $900 grants has been awarded April 1991 rule changes. The Department of Human Services has assigned administrative responsibilities for the Community Health Program grants to the Office of Planning, Research and Development (OPRD). The Division of Program Analysis and Development (DPAD), a division of OPRD, will be responsible for the administration of the Community Health Program grants (CHP grants). All grants awarded will be governed by the policies contained herein and/or as issued by the Department. Inquiries may be directed to: Director, Division of Program Analysis & Development Office of Planning, Research and Development 35 Anthony Avenue Department of Human Services 11 State House Station Augusta fb88 04333 Telephones (207) 626-5424 CHAPTER 2 - PURPOSE OF MANUAL This manual has been developed to provide a reasonable standard of conduct in the purchase and administration of all services supported by state funds for this program. This manual will also assist the grant recipients with administrative guidelines and important recipient reporting requirements and dates, which may be relevant to the continuance of the recipient's award. A glossary of terms applicable to health care is also included as appendix S. CHAPTER 3 - MANUAL STRUCTURE This manual is structured so that continual updates may be provided. All pages have been Printed on loose-leaf sheets in order to make updated page replacements simple. Further, the manual is organized by chapter and page. Each new section within a chapter begins on a new page which also facilitates updated page replacement. Throughout the duration of the Community Health Program grant, the Division of Program Analysis and Development may provide the recipients with updates and additional grant related date. CHAPTER 4 - ELIGIBILITY Eligible grantees are local medical care Providers and/or new organizations which demonstrate the capacity to provide an organized system of Primary care. Eligible grantees may include but are not limited to: A. Primary Health Care Center B. Physician or Group of Physicians C. Health Maintenance Organization (HMO) D. Hospital Outpatient Department I. PRIMARY CARE GRANTEES The grantee must also meet all of the following criteria: A Arrangements for services 24 hours a day, 7 days a week; B. Full hospital privileges for all Primary care physicians or arrangements to refer patients for inpatient hospital care and specialist services. Arrangements must be in writing or the provider must be able to demonstrate that patients are being accepted and treated; C. Provisions for follow-up care from the hospital or specialist to the patients primary care provider; D. Access to ancillary services including laboratory, pharmacy and radiology; E. Linkage to the Women, Infant and Children Special Supplemental Food Program (WIC), nutritional counseling, social and other support services; F. Acceptance without limits of Medicaid and fb88 Health Program patients and uninsured persons, including public notice of appropriate sliding fee scales; G. A medical record system with arrangements for the transfer of records to the hospital, the specialist and their return to the primary care physician; H. Quality assurance mechanisms to evaluate the Quality and appropriateness of patient care; and I. Evidence of community-wide input into the design and provision of health services to be funded by the grant (such as community based councils, Public meetings, etc.) J. Assurance that access will be provided for pregnant and parenting teens if providing prenatal care services. II. HEALTH PROMOTION AND EDUCATION GRANTEES To qualify for a health promotion and health education grant an eligible grantee must demonstrate an ability to coordinate services and programmatic efforts with local primary care providers and provide a plan for follow-up care for their consumers. III. APPLICANT QUALIFICATIONS (20) A. Arrangements for services 24 hours a day, 7 days a week. B. Full hospital privileges for all primary care physicians or arrangements to refer patients for inpatient hospital care and specialist services. Arrangements must be in writing or the provider must be able to demonstrate that patients are being accepted and treated. C. Provisions for follow-up dare from the hospital or specialist to the patients primary care provider.- D. Access to ancillary services including laboratory, pharmacy and radiology; E. Linkage to the Women, Infant and Children Special Supplemental Food Program (WIC); F. Acceptance without limits of Medicaid and fb88 Health Program patients and uninsured persons including public notice of appropriate sliding fee scales; G. A medical record system with arrangements for the transfer of records to the hospital, the specialist and their return to the primary care physician; H. Quality assurance mechanisms to evaluate the quality and appropriateness of patient care; I. Evidence of community-wide input into the design and provision of health services to be funded by the grant (such as community based councils, public meetings, etc. J. Assurance that access will be provided for pregnant and parenting teens if providing for prenatal care services. CHAPTER 5 The Department anticipates awarding no less than 80% of the funds to Primary Care grantees with most first year awards of no more S50,000.00 per grant. If your agency meets the basic eligibility requirements outlined in Chapter 4, its application will be referred to a Grant Review Committee which will be responsible for reading, evaluating and scoring the application. The Grant Review Committee will score the applications based on the groups of selection criteria below. Please note relative weights are shown in parenthesis. I. SELECTION CRITERIA A. Primary Care Grantees The selection of recipients shall be based on: 1. ASSESSMENT OF COMMUNITY NEEDS (40) a) Documented health status needs; b) Documented community financial hardship; c) Evidence of problems of access to health care 2. LIKELIHOOD OF SUCCESSFUL IMPACT (40) a) Financial feasibility of proposed project b) Long-range program development including the role of community resources c) Program management plan with goals, objectives, and strategies to meet identified needs with time frames d) Program's relationship with the organization's objectives. e) Whether or not the proposed program can be or has been replicated in another community. 3. DEGREE OF COORDINATION OF SERVICES (20) a) Evidence of community-wide input into the design and provision of health services to be funded by the grant (such as community based councils, public meetings, etc.) b) Local contributions to the organization (e.g. staff, space, transportation) c) Whether the proposed project provides coordination with other necessary support services. B. Health Promotion and Education Grantees The selection of recipients shall be based on: 1. ASSESSMENT OF COMMUNITY NEEDS (40) a) Documented community financial hardship b) Evidence of problem of access to health care. c) Clearly defined risk factors. d) Clearly defined target group characteristics 2. LIKELIHOOD OF SUCCESSFUL IMPACT (40) a) Financial feasibility of proposed project b) Program's Management plan with goals and objectives c) Pro-gram's relationship with the organization's objectives d) Whether or not the proposed program can be or has been replicated in another' community. 3. DEGREE OF COORDINATION OF SERVICES (20) a) Evidence of community-wide input into the design and provision of health services to be funded by the grant (such as community based cots-polls, public meetings, etc.) b) Local contributions to the organization staff, space, transportation) c) An ability to coordinate services and programmatic efforts with local primary care providers and follow-up care for their clients. d) Whether the proposed project provides coordination with other necessary support services. II. GRANT REVIEW COMMITTEE A Grant Review Committee shall be established to read, evaluate and score each application. The Committee will be responsible for recommending to the Commissioner, which grants should be approved. The Grant Review Committee shall consist of three (3) consumers, one of whom shall be chairperson in addition to three other members as follows: A) one doctor B) two Department of Human Services representatives The Grant Review Committee shall follow the selection criteria and guidelines as established and updated. CHAPTER 6 - The Process The Department of Human Services recognizes the need for an effective and expedient application process. In order to provide an expedient systematic and fair process the following time tables will be followed as closely as possible Date: Technical Assistance Meetings Date: Applications received by the Office of Planning Research & Development by 5 p.m. Any applications received after this deadline will be returned to the project sponsor. Date: Applications forwarded to Grant Review Committee. Date: Review Committee Recommend award recipients to Commissioner. Date: Committee Recommendations announced. Date: Deadline for appeals to be filed by denied applicants Date: Commissioner Finalizes Awards Date: Awards made Applicants should be aware that because of the need for an expedient and efficient process, applications should be completed in accordance with the instructions in appendix Al sections I and 2. Grants may be awarded for a period up to 3 years. If a grant is awarded for less than 3 years, it may be renewed provided the total term of the grant does not exceed 3 years. After a grantee has received a grant for 3 years, it may apply for an additional grant. The Department of Human Services will evaluate the application with other grant applicants in an open competitive bidding process. Applications should be submitted with an original and two copies to: Director, Division of Program Analysis and Development, Department of Human Services 151 Capital Street 11 State House Station Augusta, fb88 04333 CHAPTER 7 - COMMENT & APPEAL After the committee makes its recommendations, an applicant may comment on those recommendations. Such comments could include material changes of recommended award/awards, or may include reasons a denial was unjust. Comments must be received in writing no later than ten (10) working days after the committee makes its recommendations. Comments must be sent to the Division of Program and Analysis and Development, 151 Capital Street, Augusta, fb88 04333. The Commissioner will make final decisions about awards based on committee recommendations, scoring criteria and comments received. Aggrieved applicants, may appeal the Commissioner's decision pursuant to 5 MRSA, 11001. EFFECTIVE DATE : January 23, 1990 AMENDED: December 25, 1990 EFFECTIVE DATE (ELECTRONIC CONVERSION): May 5, 1996 APPENDIX A - COMMUNITY HEALTH PROGRAM APPLICATION INSTRUCTIONS This application is to be developed in two sections. The first section will consist of narrative description of the project and the second section will consist of financial information. It is important that both sections be submitted simultaneously. The application must be submitted as an original and with two copies. A signed cover letter by an authorizing organization official should accompany the application. The cover letter should be a brief abstract describing the objective of the proposal and the basic approach or methodology to reaching the proposed objectives. Quarterly reporting should be milestones accomplished in accordance with your responses to the narrative questions. All questions in this section should be answered as completely as possible. APPENDIX A SECTION 1 - PROGRAM DESCRIPTION This section of your application must be typewritten and double spaced. ALL APPLICANTS must answer the questions in this section. 1) Describe your organization and its structure, identifying principals and their backgrounds. 2) Describe Your current available services, and your organizations' potential to provide the proposed services from Your current base. 3) Describe in detail the community commitment to this project. Evidence of support would be in-kind services, equipment, space, etc. 4) Explain how you propose to make this program self-sustaining after the maximum allowable grant funding period. 5) Explain whether or not this program is a replica from another community or if it can be replicated in another community. 6) Describe any source of local financial support for the proposed program that will exist and provide documentation for source. 7) Describe other funding sources you intend to use or share with the proposed Program. 8) Describe any subcontracted services you anticipate utilizing in this program and Your basis why the services are being subcontracted and not provided by you. Please note the requirements in Appendix D of this document which your subcontract must meet. SECTION 1a - PRIMARY HEALTH CARE APPLICANTS Primary Health Care applicants must answer the following questions in addition to the questions in section 1: 9) Describe the problem you are addressing in this Proposal. Include documented need, address community hardship and describe any Problems with access your constituents may have. 10) Provide a detailed statement of how you propose to address the problem described in item 9. You must include a clear statement of goals and achievable objectives; a management plan and timetable (not to exceed the 3 year maximum) specifying strategies to accomplish your objectives, key actions and milestones, roles and capabilities of responsible individuals and organizations. Demonstrate the ability to coordinate services and programmatic efforts with local primary care providers. Also include a management plan showing objectives, tasks needed in order to achieve those objectives and timetable with measurable milestones, roles of responsible individuals and organizations. 11) Describe with measurable objectives. the impact your proposal will have to improve your community's access to health care. You should address such things as diversification of services, health professional recruitment, transportation, community economics and others. SECTION 1b - HEALTH PROMOTION AND EDUCATION APPLICANTS Applicants for the Health Promotion and Education awards must answer the following questions in addition to the questions in section 1. 9) Describe the risk factors you are addressing in this proposal. Identify the prevalence of the risk factor relative to other factors among a targeted population. 10) Describe your target group's special needs and characteristics and address whether or not access and participation will be a problem in your proposed program. 11) Provide a detailed management plan with a clear statement of goals and measurable objectives. Include a, description with timetables of the tasks necessary to meet your objectives. You must also include organizational resources, capabilities of responsible individuals for a 3 year period. APPENDIX A - SECTION 2 BUDGETARY AND FINANCIAL - INFORMATION All grantees receiving Public funds must disclose all related financial information prior to approval of any grant. Further, all CHP funds must be limited to costs associated with the delivery of the service. A financial glossary explaining allowable and non-allowable expenses is enclosed as Appendix C. The financial section is comprised of a series of forms designed to summarize and justify a provider organization's financial plan. It is necessary for the grantee to determine the following: (1) all income which may reasonably be expected to be received by the provider organization during the grant year; and (2) all expenses which may reasonably be expected to occur during the grant year. All budgets should be prepared for a three (3) year period unless the program is for a lesser limited time period which should be stated. The Community Health Program shall determine allowable grantee expenditures based upon the principle of functional accounting (cost sharing). Only balanced budgets will be approved. INCOME BUDGET FORM (CHPF-003) On this form, list all anticipated program income for the period of performance of the proposed grant. Include both restricted and non-restricted income. The amounts of the income listed must actually be available to the program. EXPENSES BUDGET FORM (CHPF-004) On the Expense Form list all anticipated Program expenses for the period of performance of the grant on an annual basis. Be sure to fill in each years' expense and total all three columns in column 4. Sub-total each category as requested and provide a total program expense amount on the last line as requested in total program amount column. All expenses in the Community Health Program must be Justified-on a budget Justification form Expenses such as salaries and fringe benefits which are direct expenses will be documented on CHPF-005. All other direct expenses shall be documented on either CHPF-006, Basis of Distributing Shared Direct Expenses, or on CHPF-007, Other Direct Expense Justification. Indirect costs shall be documented on CHPF-008, General and Administrative Expenses or other approved format. COMMUNITY HEALTH PROGRAM PROGRAM INCOME - BUDGET (CHPF-003) PERIOD OF PERFORMANCE_____________________________________________ FUNDING SOURCE YEAR 1 YEAR 2 YEAR 3 1) STATE/FEDERAL a) b) c) TOTAL 2) LOCAL FUNDING a. b. c. TOTAL 3) PRIVATE FUNDING a) b) c) TOTAL 4) PROGRAM INCOME a) Client Fees b) Consult Fees c) d) TOTAL 5) OTHER INCOME a) b) c) TOTAL TOTAL INCOME COMMUNITY HEALTH PROGRAM PROGRAM EXPENSES-BUDGET (CHPF-004) LINE ITEMYEAR 1YEAR 2YEAR 3PERSONNEL EXPENSES 1. Salaries & Wages 2. Fringe Benefits 3. Consultant Fees 4. Providers Fees5. TOTAL PERSONNEL EXPENSESEQUIPMENT 6. Purchases 7. Rental8. TOTAL EQUIPMENT EXPENSESSUBCONTRACTS 9. TOTAL SUB-CONTRACTSALL OTHER 10. Occupancy Expense 11. Depreciation 12. Utilities 13. Heat 14. Maintenance 15. Telephone 16. Materials & Supplies 17. Travel 18. Insurance 19. Postage 20. General and Administrative (indirect) 21. Other (attach detail)22. TOTAL ALL OTHER EXPENSES 23. TOTAL EXPENSES (lines 5, 8, 9, & 22) PERSONNEL. EXPENSES FORM (CHPF-005) This form provides back-up documentation for lines and 2 of the Expenses Budget Form (CHPF-004). Complete the form as follows: Column I Is used to show the number of people to be employed for a particular position at one salary level. Full time persons should be listed. Part-time employment should be indicated by the number of hours spent per week rather than by 1/2 or 1/4 person; Column 2 Give persons title who will be involved directly in the program. Column 3 This rate is for one individual. if rates differ, use another line Column 4 This is the total number- of hours worked for a week for-all personnel listed on that line. Column 5 Is determined by multiplying column 3 by column 4 Column 6 Is the total number of weeks during the period of performance of the grant that that the individual will be working; Column 7 Is determined by multiplying column 5 by column 6 Column 8 Self-explanatory Column 9 Is determined by multiplying column 7 by column 8 by column I Total Salary Enter column 7 total in Summary Section, Total Salary for proposed year. In the fringe benefits section, fill in the name of the benefit in the first column; the percentage applied in determining expenses in the second column; and the dollar amount for each benefit in the third column. Total the percentage and expense columns. Enter total expense for fringe benefits in the proposed year column of the summary section. Add the Total Salary and Total Fringe. Enter the Total Number of Personnel. Total Salary and Total Fringe should be the same as on lines and I and 2 respectively of the Expenses Form CHPF-004. COMMUNITY HEALTH PROGRAM PERSONNEL EXPENSES (CHPF-005) PROGRAM____________ PERIOD OF PERFORMANCE____________ (1) No. of Personnel(2) Position or Title(3) Hourly Rate(4) Total Weekly Hours(5) Weekly Salary(6) Number Weeks(7) Total Salary for Grant Period(8) % Time Spent on this Program(9) Total Program Salary for GrantFRINGE BENEFITSType of Benefit% PayrollExpenseSUMMARYPROPOSED YEARTotal SalaryTotal FringeTotal Salary & FringeTotal Number of Personnel BASIS OF DISTRIBUTING SHARED DIRECT EXPENSES (CHPF-0 06) Direct-costs are costs which can be identified with a particular pro-gram of the sponsoring agency. All direct costs shall be charged directly to the applicable program. Occasionally, a direct cost may be applied to more then one program. CHPF-006 is used to document all direct costs (excluding salaries) listed on the Program Expense form CHPF-004, that are shared between one or more programs. Complete the form as follows: (1) Part A, Type of Pool and Part B, Distribution of Base: Some common examples of cost pools and allocation bases are: Cost Pools Distribution Base Administrative Costs 1. Number of personnel 2. Accumulated costs 3. Percentage of total payroll Operation and Maintenance 1. Square feet of area of Building occupied 2. Number of personnel (2) Part C, Components of Pool: List all line items (line items should correspond to line items on Program Expense Form) which are associated with cost pool and are allocated using the some base distribution. In addition, list the total expenses for the line items within the cost pool for the period of the proposed grant. (3) Part D, Allocation of Pool: All programs sharing in these expenses must be listed. The number of base units assigned to each must be identified and the percentage of total base units assigned to each must be determined. (4) Part E, Program Costs: The percentage of units assigned to the Program is multiplied times each line item amount in Part C, Total Expenses, to arrive at the Program costs. The resulting amounts must equal those listed on the corresponding lines of the Program Expense form. COMMUNITY HEALTH PROGRAM BASIS OF DISTRIBUTING SHARED DIRECT EXPENSES (CHPF-006) A. TYPE OF POOL:B. DISTRIBUTION BASE:C. COMPONENTS OF POOL:TOTAL EXPENSESCHP PROGRAM EXP1.2.3.4.5.6.7.8. TOTAL$$ D. ALLOCATION OF POOL:PROGRAM OR COST CENTERDISTRIBUTION OF BASE UNITS% OF TOTAL UNITS1.2.3.4.5.6.7.8. TOTAL OTHER DIRECT EXPENSE JUSTIFICATION (CHPF-007) This form is used to explain all direct line item expenses listed that are-not shared with another program. Expenses should be briefly and clearly explained. COMMUNITY HEALTH PROGRAM OTHER DIRECT EXPENSES (CHPF-007) PROGRAM: PERIOD OF PERFORMANCE line item no. -Description of line item - Basis of ExpenseTotal line item exp  GENERAL AND ADMINISTRATIVE EXPENSES (CHPF-008) A simplified form (CHPF-008) is included for your use, OTHER FORMATS MAY BE USED UPON APPROVAL OF THE GRANT MANAGER. a. In Section 1, column 1, Total Agency Expenses, record all anticipated expenses of the sponsoring agency for the period of performance of the proposed grant. In column 2, Exclusions and Unallowables, list any expenses not allowable. In column 3. General and Administrative Expenses specify the amount of total allowable agency expenditures that will be used for general and administrative expenses and that will be shared among the sponsoring agency's program. b. From the total general and administrative expenses listed in column 3, line 22 subtract line 23, G & A credits applied to general and administrative expenses. G & A CREDITS ARE defined as specific purpose funds applied against general and administrative expenses. These funds must be deducted from the total allowable general and administrative costs to determine net allowable general and administrative expenses. CHP funding will be based on not allowable general and administrative expenses (section 1, line 24) c. In Section 11, Part A, indicate the basis for the distribution of the general and administrative expenses, for example, accumulated costs, number of personnel, percentage of total payroll. d. In Section 11, Part 8, record in box (1) the total base units for the entire agency. Of that total indicate in box (2) the amount of units assigned to this program and (3) the amount of units assigned to all other programs operated by the parent agency. Box (4) will always be 100%. Determine in box (5) the percentage of the total base units assigned to this program and in box (6) determine the percentage of base units assigned to all other programs operated by the parent agency. e. In Section II, Part C, determine the Program's share of the general and administrative expenses by multiplying the Balance of Administrative Expenses Shared Among Programs (Section 1, Line 24) by the Program's Percentage of Base Units (Section II, Part 8, Subsection 5). This figure should appear on Your Program Expense (CHPF-004) in the general and administrative line item. COMMUNITY HEALTH PROGRAM GENERAL AND ADMINISTRATIVE EXPENSES (CHPF-008) PERSONNEL EXPENSESSection I (1) Total Agency Expenses(2) Exclusions & Unallowables(3) General Admin Expenses 1. Salaries & Wages 2. Fringe Benefits 3. Consultant Fee 4. Providers Fee5. Total Pers. ExpEQUIPMENT 6. Purchases 7. Rental8. Total Equip ExpSUBCONTRACTS9. Total Sub-contractsALL OTHER 10. Occupancy Expense 11. Depreciation 12. Utilities 13. Heat 14. Maintenance 15. Telephone 16. Materials & Supplies 17. Travel 18. Insurance 19. Postage 20. Other (attach detail)21. Total All Other(lines 5, 8, 9, & 21) 22. TOTAL EXPENSESLess G & A Credits applied to General & 23. admin expensesBalance of Admin Exp 24. Shared Among Prog.SECTION IIA. BASIS OF DISTRIBUTION OF GENERAL & ADMINISTRATIVE EXPENSES:b. TOTAL BASE UNITS (1)THIS PROGRAM (2)ALL OTHER PROGRAMS (3)% Direct Salaries(4)(5)(6)C. PROGRAM SHARE OF GENERAL AND ADMINISTRATIVE EXPENSES $ DETERMINATION OF CHP PERCENTAGE OF EXPENSE REPORT (CHPF-010) It is important to complete this form correctly. In Section A: Complete the income and expense entries based upon anticipated budget. In Section B: List adjustments (eliminations and unallowables) to the income and expense columns. Determine the Balance by subtracting the Expenses column from the Income column. Total the Income, Expenses and Balance columns. In Section C: Determine total available for cost-sharing by subtracting the total adjustments 'B' from Total-per Reports in 'A'. In Section D: Bring totals from 'C' to respective Total columns in "D", (Available Income, Allocated Expense and Balance columns. (1) List all funding sources, including client fees. (2) List % of total income budget (from CHPF-003) (3) List available (actual) income from each funding source under 'Available Income' (4) Determine % of Available Income for each funding source. List % under % of Total Available Income" column. (5) Apply % of each funding source to Total available for cost sharing, to determine the Allocated Expense for each source. (6) Subtract Allocated Expense column from Available Income column for each funding source to determine balance due each funding source. IN-KIND CONTRIBUTIONS For all In-kind contributions, list on a separate page the sources and the value of all anticipated In-Kind contributions and attach to the grant. COMMUNITY HEALTH PROGRAM DETERMINATION OF CHP PERCENTAGE OF EXPENSE REPORT (CHPF-010) AGENCY NAME PROG TITLEPERIOD OF PERFORMANCE:TOIncomeExpenseBalanceA.TOTAL -Per Reports to DPAD B.ADJUSTMENTS     C.TOTAL ADJUSTMENTSD.COST SHARING Funding Sources% of total Income Bud.% of total Avail IncomeAvailable IncomeAllocated Bal ExpenseTOTALS APPENDIX B GLOSSARY OF HEALTH CARE TERMS 1) ACCESSIBILITY: In connection with the provisions of PL 93-641, the degree to which an individual's entry to the health care system and receipt of services is inhibited or facilitated. Factors include such things as insurance coverage and transportation. 2) ACUTE CARE: Treatment of an injury or disease of a short term nature within a medical/surgical hospital. 3) ADMISSION RATE: The number of persons admitted annually to health care facilities within a community, usually expressed as a number per 1,000 persons in the community. It also may be based on the population served by a particular institution. 4) AMBULATORY CARE: Health care delivered to patients who transport themselves and do not occupy a hospital bed. 5) ALLOPATHIC/OSTEOPATHIC/HOMEOPATHIC PHYSICIAN: An Allopathic physician is one who is practicing a philosophy of medicine which views the role of the physician as an active interventionist who attempts to counteract the effect of a disease by using surgical or medical treatments which produce effects opposite to those of the disease. The practice of an Osteopathic physician, on the other hand, is based on the theory that diseases are due chiefly to the loss of structural integrity which can be restored by manipulation of the body parts in combination with therapeutic measures. A Homeopathic Physician generally uses a drug therapy which reinforces the body's natural self-healing process. 6) AMBULATORY SURGICAL FACILITY: A facility, not part of a hospital, which provides surgical treatment to Patients not requiring hospitalization. This term does not include the offices of private physicians or dentists, whether in individual or group practice. 7) AT RISK: An insurance concept that refers to a group or community's Potential to experience health problems. For example, a group of elderly persons would be expected to experience more health problems than a younger population. 8) AVAILABILITY: The degree to which the supply of health resources and services exists to meet the needs or demands of a community. 9) BASIC LIFE SUPPORT SERVICES: Basic medical services delivered by emergency medical personnel. 10) BIRTHING CENTER: A free standing facility for the delivery of children, normally emphasizing deliver by midwife. 11) BOARDING CARE FACILITY: A home that is primarily engaged in providing to three (3) or more persons: a. Personal care, supervision and social services for persons 18 years of age or over who are ambulatory and who do not have such an illness, disease, injury or other conditions as to require the degree of care and treatment which a hospital or skilled nursing care facility or intermediate care facility is designed to provide. b. Such care and services under-the supervision of sufficient personnel to provide adequate care for its residents during all hours of each day and all days of each week. 12) CAPITAL EXPENDITURE: An expenditure, including a force account expenditure, which under generally accepted accounting principles is not properly chargeable as an expense of operation and maintenance and, for the purposes of certificate of need, shell include capitalized interest on borrowed funds and the fair market value of any property or equipment which is acquired under lease or comparable arrangement or through donation. Generally, an expenditure which benefits more than one accounting period, which is generally one year in length. 13) CAPITATION: A method of payment for health services in which an individual or institutional provider is paid a fixed per capita amount for each person served without regard to the actual number or nature of services provided to each person. Capitation is characteristic of health maintenance organizations. 14) CATEGORICALLY NEEDY: Under Medicaid (Title XIX), persons aged, blind, disabled, or a member of a family with children under la with one parent absent, incapacitated or unemployed. 15) CHRONIC CARE: Health care for diseases or problems that are characterized by permanence, residual disability, non-reversible pathological alteration. special rehabilitation or prolonged duration. 16) COMPUTERIZED AXIAL TOMOGRAPHY (CAT): A diagnostic imaging device which uses a computer to analyze the differential strength of X-ray beams Scanner Passed through body tissues in order to locate and identify abnormalities. 17) CONGREGATE HOUSING: A residential environment which provides support services, such as meals, housekeeping, health care, etc. It is designed to assist impaired, but not ill, elderly to maintain (or return to) a semi-independent life style. 19) CONTINUITY: The concept that people who experience disease or injury should have some agent (either a person or an organization) which assumes responsibility for assuring the provision of needed care. As needs of the patient are addressed, the person is not passed from one provider to another with no overall care management. 19) ELIGIBILITY: Condition that must exist or be met if a person is to Qualify for a government program. 20) FISCAL YEAR: Any yearly period at the end of which a firm, government, etc., determines its financial condition without regard to the calendar year. 21) GENERIC DRUG: A pharmaceutical compound not marketed under a brand name. 22) HEALTH MAINTENANCE ORGANIZATION: a public or private organization which: a. Provides or otherwise makes available to enrolled participants health care services, including at least the following basic health services: usual physician services, hospitalization, laboratory X-ray, emergency and preventive health services and out-of-areas covered. b. Is compensated, except for copayments, for the provision of the basic health services to enrolled participants on a predetermined periodic rate basis; and c. Provides Physicians' services primarily through physicians who are either employees or partners of the organization or through arrangements with individual physicians or one or more groups of physicians. 23) HEALTH SERVICE AREA: A geographic area appropriate for the effective planning and development of health services. 24) HEALTH SHORTAGE AREA: A geographical area or group of communities that looks an adequate number of one or more of the various health Professions. 25) HOME HEALTH CARE: Component of a continuum of comprehensive health care where health services are provided to individuals in their place of residence for the purpose of promoting, maintaining or restoring health or of maximizing the level of independence while minimizing the effects of disability and illness, including terminal illness. 26) HOMEMAKER SERVICES: Services provided by a person employed by a health or welfare agency to furnish home help to families with children; to convalescent, aged, acutely or chronically ill and disabled persons; or to all of these. The primary functions are the maintenance of household routine and the maintenance or creation of wholesome family living in times of stress. 27) HOSPITAL: An institution which is primarily engaged in providing to inpatients by or under supervision of physicians, diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled or sick persons, or rehabilitation services for the rehabilitation of injured, disabled or sick persons. 28) HYPERTENSION: Abnormally high blood pressure. 29) INCIDENCE: The frequency of occurrence of events. 30) INCIDENCE RATE: The incidence of conditions per 1,000 persons in a Population during a period of time (usually one year). 31) INPATIENT: The condition of remaining in health care facility overnight. 32) INTENSIVE CARE UNIT (ICU): A specialized nursing unit that concentrates seriously ill patients needing constant observation. 33) INTERMEDIATE CARE FACILITY (ICF): An institution which provides, on a regular basis, health-related care and services to individuals who do not require the degree of care and treatment which a hospital or skilled nursing facility is designed to provide, but who because of their mental or Physical conditions require health-related care and services above the level of room and board. 34) LENGTH OF STAY: The number of days a patient is in a health care facility. 35) LICENSE: A Permission granted by a government to an individual or organization authorizing the provision of health care services or the establishment and operation of a health care facility. 36) LONG TERM CARE FACILITY: An institution that provides care for the chronically ill, the aged, the disabled and the retarded. 37) MEDICAID (Title XIX, SOCIAL SECURITY ACT): A federally-aided, State operated and administered program which provides medical benefits for certain low-income persons in need of health and medical care. 38) MEDICALLY NEEDY: In the Medicaid program, persons who have enough income and resources to pay for their basic living expenses (and so not need welfare), but not enough to pay for their medical expenses. 39) MEDICARE (Title XVIII, SOCIAL SECURITY ACT): A nationwide health insurance program for people age 65 and over, for persons eligible for Social Security disability payments for over two years, and for certain workers and their dependents who need kidney transplantation or dialysis. 40) NATIONAL HEALTH SERVICE CORPS (NHSC): A federal program that provides health manpower to areas that do not have an adequate supply of appropriate health care professionals. 41) PEER REVIEW: The evaluation of health Professionals by their peers. 42) PEDIATRICS: A branch of medicine dealing with the development, care and diseases of children. 43) PERINATAL: The period around the birth of a child. There are several technical definitions. A commonly used one is from the 20th week of gestation to the 28th day of life. 44) PRENATAL CARE: Preventive and diagnostic care and treatment rendered to a mother during pregnancy. Pregnancy is divided into three three-month periods known as trimesters. 45) PREVALENCE: The number of cases of a disease present at a particular time in a particular population. 46) PREVALENCE RATE: The number of cases of a disease present at a particular time in a given population per 1,000 persons in the population. 47) PRIMARY CARE: Basic or general health care which emphasizes the point when the patient first seeks assistance from the medical care system and the care of the simpler and more common illnesses. The primary care provider usually also assumes ongoing responsibility for the patient in both health maintenance and therapy of illness. It is comprehensive in the sense that it takes responsibility for the overall coordination of the care of the patient's health problems, be they biological, behavioral or social.. The appropriate use of consultants and community resources is an important part of effective primary care. Such care is generally provided by physicians, but is increasingly provided by other personnel such as family nurse practitioners. 48) QUALITY: connection with the provisions of PL 93-641. the extent to which health care services are delivered in accordance with established professional standards in terms of structure, process and outcome. Elements of quality health care include technical competence, respect for the patient, treatment method, length and environment, and effectiveness. 49) REIMBURSEMENT: To pay back to someone. Payment for health care services can be made by the patient (self-pay), his insurer (e.g., Blue Cross/Blue Shield or Union Mutual) or a third party purchaser of care (e.g., Medicaid). 50) SKILLED NURSING FACILITY: An institution or distinct part of an institution which is primarily engaged in providing to inpatients skilled nursing care and related services for patients who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled or sick persons. 51) SUPPLEMENTAL SECURITY INCOME (SSI): A program of income support for low-income, aged, blind or disabled persons. APPENDIX C - FINANCIAL GLOSSARY PROGRAM INCOME: The funds received by a program from a particular funding source is considered to be program income. Such funds may be either restricted or unrestricted. For greater clarity, the following definitions are offered: Restricted Funds funds received by the provider which are required by the funding source to be used to purchase certain goods or services or to pay for certain expenses. Restricted funds may be in the form of grants or donations. The Community Health Program grant award settlement will be based on net allowable expenses. Restricted funds must be applied against expenditures to which the-funds are restricted. Those expenditures are not subject to payment by Community Health Program (CHP) funds- Thus, if a provider has received a specific purpose grant to pay the salaries of certain positions, the salary cost of those positions must be deducted from total allowable costs to determine net allowable costs. CHP grant award will be based on net allowable expenses. Unrestricted Funds funds received by the provider which may be used as the provider deems appropriate, so long as: (a) The funds are not previously described in this section, (b) CHP does not participate in the costs, including indirect costs, of producing such funds, and (c) The agency Board of Directors has established how funds will be used. Major sources of funding are: (1) STATE/FEDERAL Funding This includes but is not limited to income from the federal and state government. (2) LOCAL Funding This includes income from county or municipal governments. (3) PRIVATE FUNDING This includes endowment funds, and awards/funds from private agencies, United Way service or organizations available to the program. (4) PROGRAM INCOME includes: (a) Client Fees (including third Party reimbursement) (b) Sales of Goods and Services (c) Donations (d) Earned Interest (e) other Income: from sale of property, equipment or supplies. Workshop income and usage or rental fees in which CHP participated in the costs thereof. AUDITING STANDARDS Grants to applicants made pursuant to these rules will be audited according to the standards set forth below. The Department shall recover funds that fail to meet those standards. The Department shall utilize the cost principles and administrative requirements contained in the following US office of Management and Budget (OMB) circulars as applicable to the type of community agency entity being audited (unless there is a conflict between the applicable circular and the allowable and non-allowable expenses set forth below in which case the latter shall apply). (a) Public Entity i) OMB Circular A-102, Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments ii) OMB Circular A-87, Cost Principles for State and local Governments (b) Nonprofit Entity i) OMB Circular A-110, Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education, Hospitals, and Other Nonprofit Organization ii) OMB Circular A-122, Cost Principles for Nonprofit Organizations (c) Educational Entity i) OMB Circular A-110, Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education, Hospitals, and Other Nonprofit Organizations ii) OMB Circular A-21, Cost Principles for Educational Institutions iii) OMB Circular A-88, Indirect Cost Rates, Audit, and Audit Follow-up at Educational Institutions (d) For Profit Entity i) OMB Circular A-102, Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments ii) OMB Circular A-87, Cost Principles for State and Local Governments. ALLOWABLE EXPENSES The following are allowable expenses under the Community Health Program grant award: (1) ACCOUNTING EXPENSES those costs which include establishing and maintaining accounting and other information systems required for the management of grant programs. Agency audits are an allowable administrative expense. (2) ADMINISTRATIVE COSTS general expenses necessary for the total operation of the agency of which the program is a part. (3) ADVERTISING COSTS - ONLY FOR: (a) recruitment of personnel required for the performance of obligations arising under the grant by the provider when considered in conjunction with all other recruitment costs; (b) to fulfill specific requirements of the CHP grant. These costs consist of the costs of advertising media including magazines, newspapers, radio and television pro-grams, direct mailing, trade Papers, outdoor advertising, dealer cards, window displays, convention exhibits, free goods and samples, and the like. (4) BONDING COSTS costs necessary to assure against financial loss of CHP funds. Included are such bonds as bid, performance, payments, advance payments, infringement, and fidelity bonds. (5) CAPITAL EQUIPMENT/BUILDING COSTS Purchase and/or rental of movable equipment or of building is allowable only with approval of the Division of Program Analysis and Development (DPAD). Capital equipment costs of $500 or more for equipment, buildings, and/or repairs which materially increase the value or useful life of equipment or buildings. (6) COMPENSATION FOR PERSONAL SERVICES Immediate or deferred compensation for personal services rendered by employees of the provider agency during the grant period. It includes, but is not limited to salary, wages, and management-employee incentive compensation plans. (7) CONSUMABLE SUPPLIES include linens, paper, and other materials necessary to carry out the objectives of the grant. (8) CONSULTANTS the cost of purchasing expert service advice or services for both direct service and program administration. This may include expense of travel ( see 'Travel Costs') as well as reasonable consultant fees. (9) DEPRECIATION AND USE ALLOWANCE depreciation is a charge to-current operations which distributes the cost of the tangible capital asset, less estimated residual value, over the estimated useful life of the asset in a systematic and logical manner. It does not involve current market value of the asset. Useful life refers to the prospective period of economic usefulness life. Use allowances are the means of allowing compensation when depreciation or other equivalent costs are not considered. Any asset purchased with non-CHP funds but depreciated in a CHP grant is the Property of the provider organization. A depreciation schedule must be submitted if depreciation expense is charged to the program. (10) FRINGE BENEFITS services provided by the provider to its employees as compensation in addition to regular wages and salaries. They include such costs as contributions to employee insurance, pensions and annuities. (11) INSURANCE AND INDEMNIFICATION includes all insurance which the Provider is required to carry or which is approved under the terms of the grant (and any other insurance which the provider maintains in connection with the general conduct of its business). Indemnification includes securing the provider against liabilities to third persons and any other loss or damage not compensated by insurance or otherwise- (12) LEGAL EXPENSES expenses incurred in administering a grant program. (13) MAINTENANCE AND REPAIR COSTS costs necessary for the upkeep of property and equipment which neither add to the permanent value of the property nor appreciably Prolong its intended life, but keep it in an efficient operating condition. (14) OTHER OCCUPANCY COSTS includes such costs as heat, electricity, water, gas, telephone, sewage and garbage disposal, and snow removal. (15) PROFESSIONAL ACTIVITY COSTS these costs are allowable under the following conditions: (a) These costs are allowable insofar as their primary purpose is the dissemination of technical information or the stimulation of production. (b) These costs must be reasonable and necessary and commensurate with both the size and structure of the provider. This category includes the costs of subscriptions, meetings, conferences and agency memberships. i. Subscription costs are the cost of subscriptions to trade, business, professional, or technical periodicals. ii. Meetings and conferences costs include meals, transportation, rental of facilities for meetings, costs incidental thereto. Attendance at out-of-state meetings and conferences requires prior written notification of the (DPAD). iii. Agency membership costs are the costs of fees (dues) to appropriate professional organizations and associations. (16) PUBLIC INFORMATION SERVICES COSTS these costs are allowable under the following conditions: (a) To interest individuals or groups in participating in a service program of the provider. (b) Provide stewardship reports to state and local government agencies, benefactor foundations and associations. These costs include the costs associated with promotions, public relations, pamphlets, news releases, and other forms of information services. (17) RELATED PARTY COSTS these costs are allowable under the following conditions: (a) Costs applicable to services, facilities, and supplies furnished to the agency by organizations related to the agency by common ownership or control are includable in the allowable costs of the agency at the cost to the related organization . However, such costs must not exceed the price of comparable services, facilities, or supplies that could be purchased elsewhere. Related to the agency means that the agency to a significant extent is associated or affiliated with or has control of or is controlled by the organization furnishing the services, facilities, and supplies. Common Ownership exists when an individual possesses significant ownership or equity in the agency and the institution or organization serving the agency. Control exists where an individual or an organization has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization or institution. (b) Administrative fees paid to a related organization are allowable only to the actual expenses incurred in administering the Program, the total administrative costs of the related organization must be allocated to the various provider agencies based on acceptable cost allocation methods. The Division of Program Analysis and Development agrees to assume only that share of the indirect costs which are fairly attributable to its own grants. These costs are paid to individuals or organizations related to the provider. Related to the provider means that the provider to a significant extent is associated or affiliated with, or has control of, or is controlled by the individual or organization furnishing the facilities, services, or supplies. (18) PUBLICATION AND PRINTING COSTS prior written approval by the DPAD will be required for one-time expenditures greater then $500.00 and not previously approved in the grant. These costs are the costs of printing including the process of composition, platemaking, press work, binding, and the end product produced), distribution, promotion, mailing, and general handling. (19) RENTAL EXPENSE these costs are allowable if the rates are reasonable in light of such factors as the rental costs of comparable facilities and market conditions in the are, the type, life expectancy, condition and value of the facilities leased, options available and other provision of the rental agreement. These expenses are for the use of land, building, equipment, and other Personal property. Utilities may be included in rent expenses, if they are supplied by the renter. (20) TRAINING COSTS these costs include such things as tuition, registration fees, books trainer costs, meals and travel costs. (21) TRAVEL COSTS the maximum travel reimbursement rate will be based upon the provider organization policy and attached to the grant package. Where no policy exists, state rates Shall apply. These costs include the costs of transportation, lodging subsistence, and incidental expenses incurred by provider personnel in a travel status while on official program related business. NON-ALLOWA8LE EXPENSES The following are non-allowable expenses under the Community Health program grant award: (1) BAD DEBT these are losses (whether actual or estimated) arising from uncollectable accounts and other claims, related costs, and related legal costs. (2) CONTINGENCIES these are possible future events or conditions arising from presently known or unknown causes, the outcome of which cannot be determined. (3) DEPRECIATION AND USE ALLOWANCE OF GOVERNMENT PROPERTY these are generally items for which a grantee has government furnished equipment, facility or ground, irrespective of title status. (4) DONATED GOODS, SPACE AND SERVICES donated or volunteer services by professional and technical personnel, consultants and other skilled and unskilled labor as well as donated goods, (e.g., expendable personal property/supplies) and donated use of space may be furnished to an organization. (5) ENTERTAINMENT COSTS costs of amusements, diversions, social activities, ceremonial, and incidental costs relating thereto, such as meals, lodging, rentals, transportation and gratuities. (6) FINES AND PENALTIES these are costs resulting from the provider's violations of federal, state and local laws and regulations, or failure of the agency to comply with such laws and regulations. (7) FUND RAISING COSTS these costs include printing, personnel, advertising, etc.-, for the purpose of raising funds. (8) INTEREST the cost on borrowed capital or temporary use of endowment funds. (9) LEGAL EXPENSES these costs include attorney fees, filing fees, etc. for the prosecution of claims against federal government and/or the Department. (10) LOBBYING COSTS these costs are for the salary or expenses of any person engaged in any activity designed to influence legislation or appropriation pending before the Congress or the State Legislature. (11) LOSSES ON OTHER GRANTS OR CONTRACTS these costs include losses on other grants or contracts or any excess of costs over income on a grant or contract. (12) MAJOR REPAIRS AND RENOVATIONS these costs are those of fixed equipment. buildings, major repairs and renovations which materially increase the value or useful life of buildings or equipment. IF THESE COSTS ARE CAPITALIZED OR DEPRECIATED, THEY ARE CONSIDERED TO BE ALLOWABLE. (13) INDIVIDUAL (PERSONAL) MEMBERSHIP COSTS individual membership costs consist of the membership fees of trade, business, technical and professional organizations. (14) MORTGAGE EXPENSE these are the costs of repaying money that was borrowed using property as collateral. The interest is unallowable. The principal is allowable only if capitalized and depreciated. (15) ORGANIZATION COSTS these costs consist of expenditures such as incorporation fees, attorney's fees, accountant's fees, broker's fees, and fees to promoters and organizers in connection with the organization or reorganization of a business or raising capital. (16) VEHICLE PURCHASE these are cost relating to the purchases of vehicles. THESE COSTS MAY BE ALLOWABLE IF CAPITALIZED AND DEPRECIATED. IN-KIND CONTRIBUTIONS In-kind contributions shall be valued as follows: (a) Volunteer services from individuals shall be valued at rates the recipient organization would ordinarily pay for similar work or, if the recipient does not have any employees performing similar work, at rates other employers in the some labor market would ordinarily-pay for similar work. A reasonable amount may be included for fringe benefits. (b) Volunteer services contributed by employees in the employees normal line of work shall be valued at the employees' regular pay rate exclusive of fringe benefits and overhead costs. If the services are in a different line of work they shall be valued in the same manner as individual volunteer services above. APPENDIX D - AGREEMENTS/SUBCONTRACTS/CONTRACTS In some cases where it is necessary for the Provider organization to subcontract for the provision of some or all services, the Department of Human Services will require the following: a) Attach copies of signed subcontracts, agreements, contracts or lease agreements with individuals, agencies, corporations, other, which affect this grant, either through receipt of granting funds or through provision of direct services arrangements necessary for the fulfillment of the grant when submitting it for approval. b) Enclose a letter of commitment from any individual, corporation or agency with whom an agreement/contract/subcontract is not yet in writing. -If the application is approved, all letters of commitment must be followed by signed written agreements as stated above, prior to submission to the Commissioner for signature. c) The provider organization with which the Division of Program Analysis and Development holds the original grant shall be held responsible for fulfillment of the grant. d) The provider organization with which the Division of Program Analysis and Development holds the original grant shall be responsible for submitting to the Division all program and fiscal reports and information for the subcontracts. e) All subcontracts receiving CHP funds shall consist of: 1) Subcontract Agency Summary Page 2) Signature Page 3) Certification of Authorization 4) Subcontract Articles of Agreement 5) Rider A; 6) Rider B; (NOTE::: Riders A and B are to be attached as described in Appendix C of this grant policy manual) f) Provider organizations holding subcontracts shall perform site visits to subcontractee agencies for the purpose of testing: 1) Selected accounts; 2) Program activity (service) record keeping systems. g) Provider organizations shall Provide reports of subcontractee program activity (service) quarterly. h) Provider organizations holding subcontracts shall attach to their final reports: 1) Subcontract program activity (service) reports; 2) Subcontract final fiscal report, using CHPF-010; 3) Subcontract trial balance for the period covered in the contract. i) Provider organization shall determine allowable subcontractee expenses based upon the principle of cost sharing. The Percentage of allowable expenses shall be completed by dividing the subcontract amount by the total allowable expense of the (subcontract) program. SECTION .09 UNIFORM AND STANDARD STATE ADMINISTRATIVE PRACTICES SUMMARY: This section identifies Uniform and Standard State Administrative Practices including uniform fiscal year and agreements forms, and community agency agreement register. A. UNIFORM AGREEMENT FISCAL YEAR (1) Wherever possible, the uniform agreement fiscal year shall be for the fiscal period ending September 30. B. STANDARD AND UNIFORM AGREEMENT (1) State Departments and agencies shall. at a minimum, use the State of fb88 Standard Agreement (See Appendix VIII) whenever an agreement Is awarded by them to any community agency. Any modifications or changes to the existing contract should be attached to the Standard Agreement Summary Page. (2) Individual Federal awards and amounts and State awards and amounts will be clearly identified in Rider A of agreements. C. STANDARD AND UNIFORM ADMINISTRATIVE POLICIES AND PROCEDURES (1) As a minimum, by January 1. 1990 departments shall adopt the cost principles and administrative requirements contained in the following US Office of Management and Budget (OMB) circulars as applicable to the type of community agency entity being audited: (a) Public Entity OMB Circular A-102, Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments OMB Circular A-87, Cost Principles for State and Local Governments (b) Nonprofit Entity OMB Circular A-110. Uniform Administrative Requirements for Grants and Agreements with Institutions of Higher Education. Hospitals, and other Nonprofit Organization OMB Circular A-122. Cost Principles for Nonprofit Organizations (c) Educational Entity OMB Circular A-110, Uniform Administrative Requirements for Grants and Agreements with institutions of Higher Education, Hospitals, and Other Nonprofit Organizations OMB Circular A-21. Cost Principles for Educational Institutions OMB Circular A-88. Indirect Cost Rates, Audit, and Audit Follow-up at Educational institutions. (d) For Profit Entity OMB Circular A-102, Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments. OMB Circular A-87, Cost Principles for State and Local Governments. 2. Departments that elect to adopt exceptions to the criteria contained in these OMB circulars shall promulgate rules for such exceptions through the fb88 Administrative Procedures Act with the approval of the Commissioner of the Department of Finance. 3. By , departments shall develop program compliance requirements that are expected, as a minimum, to be covered by an audit under these rules. Such program compliance requirements shall be consolidated by the Commissioner of the Department of Finance into a state Program Compliance Manual to be completed by . MAINE DEPARTMENT OF HUMAN SERVICES COMMUNITY HEALTH PROGRAM GRANT APPLICATION APPLICANT ORGANIZATION NAME _____________________________________________________ Address ___________________________________________________ __________________________________________________________ Administrator _______________________________________________ Contact Person _____________________________________________ Telephone _________________________________________________ Program Title: ______________________________________________ Time Period: ________________________ ____________________ start date end date Amount requested: $ Grant Year __________ __________ __________ ======================================================== FOR DPAD USE ONLY: Date Received: _____________________________________________ Committee Action ___________________________________________ Amount Awarded ______________________ Division Grant Manager _______________________________________ Page 1 of STATE OF MAINE STANDARD AGREEMENT THIS AGREEMENT, made this ______________ day of ___________ 19___, is by and between the State of fb88, ___________________ hereinafter called "Department," and _______________________ hereinafter called "Contractor," located at __________________________________________________ (Street) ___________________________________________________________________________________ (City, State, zip) (Telephone Agreement dates; from ______________________ to _____________________ The Employer Identification Number of the Contractor is _____________________________________________ IRS or Social Security Number WITNESSETH. that for and in consideration of the payments and agreements hereinafter mentioned, to be made and performed by the Department, the Contractor hereby agrees with the Department to furnish all qualified personnel, facilities, materials and services and in consultation with the Department, to perform the services, study or projects described in Rider A. The following riders are hereby incorporated into this contract by reference: Rider A - Specifications of Work to be Performed Rider B - Payment and Other Provisions Rider C - If Applicable IN WITNESS WHEREOF, the Department and the Contractor, by their representatives duly authorized, have executed this agreement in ________ (Number) originals as of the day and year first above written. APPROVED AS TO FORM DEPARTMENT: Date:_____________________19____ _____________________________ Department Name By:_____________________________ By:___________________________ Attorney General Authorized Signature ______________________________ Typed Name and Title _______________________________ STATE CONTROLLER ______________________________ Contractor Name By:____________________________ Authorized Signature _______________________________ Typed Name and Title STANDARD AGREEMENT Page of RIDER A SPECIFICATIONS OF WORK TO BE PERFORMED (Briefly describe services being purchased by the State under agreement. If detailed specifications are required, refer to specifications and attach to the back of the Contract.) (Federal and State fund sources shall be identified including agency name, catalogue Federal Domestic Assistance (CFDA) number and any other grant number as applicable Compliance requirements shall be summarized and/or referenced.) STANDARD AGREEMENT Page of RIDER B PAYMENT AND OTHER PROVISIONS 1. CONTRACT PRICE $_____________________________ 2. INVOICES AND PAYMENTS. Payment shall be made by the Department after receipt of an approved itemized invoice submitted by the Contractor upon his usual billing forms or business letterhead. or upon a form required by the Department. Payments under this contract are subject to the Contractor's compliance with all items set forth in this contract and subject to the availability of funds. 3. BENEFITS AND DEDUCTIONS. If the Contractor is an individual, the Contractor understands and agrees that he Is an Independent Contractor for whom no Federal or State Income Tax will be deducted by the Department. and for whom no retirement benefits. survivor benefit insurance, group life insurance, vacation and sick leave. and similar benefits available to State employee will accrue. The Contractor further understands that annual information returns as required by the Internal Revenue Code or State of fb88 Income Tax Law will be filed by the State Controller with the Internal Revenue Service and the State of fb88 Bureau of Taxation, copies of which will be famished to the Contractor for his Income Tax records. 4. INDEPENDENT CAPACITY . The parties hereto agree that the Contractor, and any agents and employees of the Contractor. in the performance of this agreement. shall act In an Independent capacity and not as officers or employees or agents of the State. 5. CONTRACT ADMINISTRATOR. The Department shall designate a contract administrator who will act as the Department's representative. The Department shall insure that the contractor is given the name of the administrator at the time of the execution of the agreement. 6. DEPARTMENT'S REPRESENTATIVE. The Contract Administrator shall be the Department's representative during the period of this agreement. He has authority to stop the work if necessary to ensure its proper execution. He shall certify to the Department when payments under the contract are due and the amounts to be paid. Be shall make decisions on all claims of the Contractor, subject to the approval of the Head of the Department and in accordance with the policies of the Department. 7. CHANGES IN THE WORK. The Department may order changes in the work, the contract sum being adjusted accordingly. All such orders and adjustments shall be in writing. Claims by the Contractor for extra cost must be made in writing and signed by the Contract Administrator before executing the work involved. 8. PERIOD OF PERFORMANCE A. Effective Date __________________________ B. Termination Date _______________________ STANDARD AGREEMENT Page of 9. SUBCONTRACTS. Unless provided for in this contract.-no contract shall be made by the Contractor with any other party for furnishing any of the work 'or Services herein contracted for without the consent, guidance and approval of the Contract Administrator. Any subcontract hereunder entered into subsequent to the execution of the contract must be annotated "approved" by the Contract Administrator before it is reimbursable hereunder. This provision will not be taken as requiring the approval of contracts of employment between the Contractor and his employees assigned for services thereunder. 10. SUBLETTING, ASSIGNMENT OR TRANSFER. The Contractor shall not sublet, sell, transfer "' assign, or otherwise dispose of this agreement or any portion thereof, or of his right, title or Interest therein, without written request to and written consent of the Contract Administrator. No subcontracts or transfer of agreement shall In any case release the Contractor of his liability under this agreement. 11. EQUAL EMPLOYMENT OPPORTUNITY. During the performance of this contract, the Contractor agrees as follows: a. The Contractor will not discriminate against any employee or applicant for employment because of race. color, religious creed, sex, national origin. ancestry. age. physical handicap, or mental handicap. Such action shall include, but not be limited to, the following: Employment, ungrading, demotions, transfers, recruitment or recruitment advertising.- layoffs or terminations; rates of pay or other forms of compensation; and selection for training, including apprenticeship. b. The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to race. color, religious creed, sex, national origin, ancestry, age, physical handicap, or mental handicap. c. The contractor will send to each labor union or representative of the workers with which he has a collective or bargaining agreement or other contract or understanding, whereby be is furnished with labor for the performances of his contract, a notice, to be provided by the contracting department at agency, advising the "id labor union or workers' representative of the contractors commitment under this section and shall post copies of the notice in conspicuous places available to employees and to applicants for employment. d. The Contractor will cause the foregoing provisions to be inserted in all contracts for any work covered by this agreement so that such provisions shall be binding upon each subcontractor. STANDARD AGREEMENT Page of 12. EMPLOYMENT AND PERSONNEL. The Contractor shall not engage on a full-time, part-time or other basis during the period of this agreement, any professional or technical personnel who are or have been at any time during the period of this agreement in the employ of any State Department or Agency, except regularly retired employees, without the written consent of the public employer of such person. 13. STATE EMPLOYEES NOT TO BENEFIT. No individual employed by the State at the time this contract is executed or any time thereafter shall be admitted to any share or part of this contract or to any benefit that may arise therefrom directly or indirectly due to his employment by or financial interest in the Contractor or any affiliate of the Contractor. This provision shall not be construed to extend to this contract if made with a corporation for Its general benefit. 14. WARRANTY. The Contractor warrants that it has not employed or written any company or person. other than a bona fide employee working solely for the Contractor to solicit or secure this agreement, and that it has not paid, or agreed to pay any company or person, other than a bona fide employee working solely for the Contractor any fee, commission, percentage, brokerage fee, gifts. or any other consideration, contingent upon, or resulting from the award for making this agreement. For breach or violation of this warranty, the Department shall have the right to annul this agreement without liability or, at its discretion, to deduct from the contract price or consideration, or otherwise recover the full amount of such fee, commission, percentage. brokerage fee, gifts, or contingent fee. 15. ACCESS TO RECORDS. The Contractor shall maintain all books, documents, payrolls, papers, accounting records and other evidence pertaining to this agreement and to make such materials available in their offices at all reasonable times during the period of this agreement and for such subsequent periods as specified under MAAP rules. The contractor shall allow inspection of pertinent documents by the Department or any authorized representative of the State of fb88 or Federal Government, and copies thereof shall be furnished, If requested. 16. AUDIT. Funds provided under this agreement are subject to the audit requirements contained In the fb88 Uniform Accounting and Auditing Practices for Community Agencies (MAAP), and may further be subject to audit by authorized representatives of the Federal Government. 17. TERMINATION. The performance of work under the contract may be terminated by the Department in whole or, from time to time, in part whenever for any reason the Contract Administrator shall determine that such termination is in the best interest of the Department. Any such termination shall be effected by delivery to the Contractor of a Notice of Termination specifying the extent to which performance of the work under the contract is terminated and the data on which such termination becomes effective. The contract shall be adjusted and modified accordingly. 18. GOVERNMENTAL REQUIREMENTS. The Contractor warrants and represents that all governmental ordinances, laws and regulations shall be complied with. STANDARD AGREEMENT Page of 19. INTERPRETATION AND PERFORMANCE. This agreement shall be governed by the laws of the State of fb88 as to interpretation and performance. 20. STATE HELD HARMLESS. The Contractor agrees to indemnify, defend and save harmless the State, its officers, agents and employees from any and all claims and losses accruing or resulting to any and all contractors, subcontractors, materialmen, laborers and any other person, firm or corporation furnishing or supplying work, services. materials or supplies In connection with the performance of this contract, and from any and all claims and losses accruing or resulting to any person, firm or corporation who may be injured or damaged by the Contractor in the performance of this contract and against any liability. including costs and expenses for violation of proprietary rights, copyrights, or rights of privacy, arising out of publication, translation. reproduction. delivery. performance. use or disposition of any data furnished under this contract or based an any libelous or other unlawful matter contained in such data. 21. APPROVAL. This contract is subject to the approval of the fb88 Attorney General's Office and the State Controller before it can be considered as a valid document. 22. ENTIRE AGREEMENT. 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