HomeMy WebLinkAbout*Other - RenewSCHEDULE A
7,
DEVELOPMENTAL DISABILITIES
RESIDENTIAL SUPPORT PROGRAMS COST REPORT
GENERAL INFORMATION AND CERTIFICATION
PART A - PROVIDER IDENTIFYING INFORMATION
A
ROVIDERAGENCYN, ME
2. PROVIDER ONE ID'
1N - Grant County Developmental Disabilities (DCL)
2000;1
1PROVIDER MAILING ADDRESS
41'!CITYp Zip
'PROVIDER PHONE NUMBER
1103 Lowry St.
Moses Lake 98837
(509) 762-1161
6.rADMINISTRATOR
7. E-MAIL ADDRESS
8* DDA REGION ID
- '
Missy Lopez
nolo oezaqrantcount�.o v
5.. HOME OFFICE/CORPORATE NA ME Jndlcafe' lf NONE or SAME ASASO VE)
Same as above
E OFFICE MAILIN
0.* KOM Q ADDRESS
11 -:CITY AND ZIP.
E
2, HOM. 'OFFICE PHONEN .
:i 1103 Lowry St.
Moses Lake 98837
(509) 762-1161
13. COST 41EPORT PREPARER
4,TIRM NAME
Reyna Gonzales Grant Integrated Services
15.#'R.EPORT CONTACT INDIVIDUAL(S) 16., CONTACT- PHONE #
11.7.CON.TACT e'm' 111, Addiess
Reyna Gonzales 1509 764-2660
I& COST REPORT PERIOD
Egon,zales@grantcountvwa.gov
0. REPORTING PURPOSE
1/1/2020 12/31/2020 f`
C
.FROM ... ... TO.,
MIN
*'PART B. - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE
PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER STATE OR FEDERAL LAW
q g111,11 111 '11111, 111P111,111. IWIN 1.111111 ANIII I 1 1 1 1 11 111 11 loll
CERTIFICATION -0 111!
I HEREBY CERTIFY under penalty of perjury that I have read the above statement and have examined the accompanying
cost report and supporting schedules prepared for:
Directions In Community Living
(Provider Name)
and I attest, it is a true, correct and complete representation of actual' --costs related to client supports prepared in
accordanceV1
with applicable instructions pro idd"by DIPA, exce t as no e`
1A "i 6k
PERSON SIGNING MUST HAVE AUTHORITY T6'BINDTHE PROVIDER LISTED
Cindy Carter, Chair
TITLE DATE
DSHS/DDA Schedule A (Rev. 1/2020) � I ........
3/31/2021 2020 Cost Report - Template- 03.31.20 rg, A - General Info & Cert, Page 1 of 1