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ATTACHMENT B—Scope of Work Federal Tax Id. or SSN 27-3190975 <br /> Contract# <br /> A. CONTRACTOR INFORMATION <br /> 1. Contractor Agency Name: Steele Bridge Enterprises (D&D General Store) <br /> 2. If different from Contract Administrator Information in General Contract: <br /> Address <br /> Telephone Number: Fax Number: Email: <br /> 3. Name of Program (s): <br /> 4. Status: ❑ Public ❑ Private, Not for Profit x❑ Private, For Profit <br /> 5. Contractor's Financial Reporting Year July 2020 through June 2021 <br /> B. Explanation of Services to be provided and to whom (include SIS Service Code): <br /> Service Code 380- Medicaid Transportation <br /> C. Rate per unit of Service (define the unit): <br /> 1. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart) <br /> 2. Negotiated County Rate. <br /> Each gas voucher, not to exceed the amount indicated on the gas voucher by DSS <br /> staff when determining eligibility. <br /> D. Number of units to be provided: Number of individuals to be served varies and <br /> requests for service will be determined by the medical need, recipient eligibility and will <br /> be contingent upon funding. <br /> E. Details of Billing process and Time Frames; Invoices are to be submitted for payment <br /> by the fifth working day of each month. <br /> F. Area to be served/Delivery site(s): Lee County residents who meet eligibility criteria <br /> and who are authorized by the Lee County Department of Social Services. <br /> aLr71Z--- <br /> (Signature of County Authorized Person) 1"re --ontractor) <br /> (9/ i /4goa0 _ S- 16 - 2L' <br /> (Date Submitted) (Date Submitted) <br /> Contract-Scope of Work (7-2008) Page lof I <br />