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CONTRACT PROVIDER NAME: Christian Healthcare Adult Daycare CONTRACT NUMBER: -Fy 20-21 CONTRACT PERIOD: July 1, 2020-June 30, 2021 PROVIDER'S FISCAL YEAR: Janurary 1, 2020- Decemeber 31, 2020 CONTRACT DETERMINATION QUESTIONNAIRE (PURCHASE OF SERVICE VS. FINANCIAL ASSISTANCE) Instructions: Enter 5 points for each factor in either the yes or no column. Once the entire list has been completed tally the points in each column. The column with the most points should be a good indicator of the designation of the organization--either Financial Assistance(Grant)or Vendor(Purchase of Service). 5 points 5 points Determination Factors Financial Purchase Assistance of Service YES NO 1 Does the provider determine eligibility? I 5 2 Does the provider provide administrative functions such as Develop program standards procedures and rules? 5 3 Does the provider provide administrative functions such as Program Planning? 5 4 Does the provider provide administrative functions such as Monitoring? 5 5 Does the provider provide administrative functions such as Program Evaluation? 5 6 Does the provider provide administrative functions such as Program Compliance? 5 7 Is provider performance measured against whether specific objectives are met? 5 8 Does the provided have responsibility for programmatic decision making? 5 9 Is the provider objective to carry out a public purpose to support an overall program objective? 5 10 Does the provider have to submit a cost report to satisfy a cost reimbursement arrangement? 5 11 Does the provider have any obligation to the funding authority other than the delivery of the specified goods/services? 5 12 Does the provider operate in a noncompetitive environment? 5 13 Does the provider provide these or similar goods and/or services only to the funding agency? 5 14 Does the provide these or similar goods and/or services outside normal business operations? 5 TOTAL 10 60 Note: The authorized individual(s) must place an X in one of the boxes below to indicate the type of contractual arrangement for this contract , then sign and date where indicated. FINANCIAL ASSISTANCE X PURCHASE SERVICE Lesa Price t-II / Signature of Authorized Programmatic Individual DATE 1k-101 ql;p7/6 Signature Authorized Administrative Individual DA Revised effective 7-1-2013 page 1