Res 2016-001/ (“WIC”) Program Contract with Texas Department of State Health Services

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ATTACHMENT A STATEMENT OF WORK format as provided by DSHS, and shall be completed and submitted to DSHS within fifteen (15) calendar days after the end of each month; and 2. Monthly Incentive Funding Summary Report by the 15`u' day of the following month. 3. Grantee shall submit quarterly FSRs to DSHS Contract Development and Support Branch at WicVou r r slis. state. M pus by the last business day of the month following the end of each quarter of the Contract Statement of Work term for Department review and financial assessment. IV. BILLING INSTRUCTIONS AND PAYMENT Grantee shall request payment using the State of Texas Purchase Voucher (Form B -13) and Financial Status Reports (FSR) and submit by electronic mail to DSHS Contract Development and Support Branch at WicVou h _Ir I", dshs. state, tx, us. Grantee shall indicate separately on the face of the claim for reimbursement (State of Texas Purchase Voucher, Form B -13) the costs associated with nutrition education, breast - feeding, and other administrative costs. All payments made by DSHS to Grantee under this Contract will be reimbursements subject to the following requirements, conditions and stipulations: All categories of costs billed to DSHS WIC Program, and allocation of such costs, shall be in accordance with the "Plan to Allocate Direct Costs" (PADC) submitted by Grantee and approved by the DSHS WIC Program. This document is incorporated by reference and detailed in ATTACHMENT E — NON - EXCLUSIVE LIST OF APPLICABLE LAWS. DSHS will reimburse Grantee for administrative costs incurred when determining eligibility, . providing appropriate nutrition education and counseling, issuing WIC EBT cards, making participant referrals, vendor evaluation, outreach, start-up costs and general administrative support. Administrative costs will be reimbursed based on actual costs, but not to exceed the "maximum reimbursement" based upon the sum of the participants who actually receive WIC EBT cards each month plus infants who do not receive any WIC EBT cards whose breastfeeding mothers were participants to the extent that the total so derived does not exceed Grantee's total assigned caseload within any given month. Surplus funds (the amount by which maximum reimbursements exceed actual costs) can be accumulated and carried forward within the Statement of Work term. The participant caseload will be assigned by DSHS by giving written notice to Grantee. The participant caseload is subject to change upon written notice to Grantee from DSHS with Grantee's concurrence. Grantee assumes liability for all food costs resulting from Grantee exceeding its assigned caseload. The number of individuals served in excess of assigned caseload are not to be included in the calculation of earned administrative funds as described below. DSHS Contract No. 2016 - 048775 -001 Attachment A - Page 5