<p>Cover Page: AAANM Multi-Year RFP for FY 2014-2016 Aging Services Contracts</p><p>Legal Name of Applicant Federal Tax ID Number (for corporations)</p><p>Assumed Name (dba) Social Security Number (for individuals) Type of Organization Unit of general purpose government or agency thereof For-Profit Private Non-Profit Other (Specify): Geographic Service Area</p><p>Business Address</p><p>Street, PO Box</p><p>City State Zip Executive Director</p><p>Name E-mail ( ) - ( ) - Phone Fax</p><p>Street, PO Box (If different from Business Address)</p><p>City State Zip Program/Service Manager</p><p>Name E-mail ( ) - ( ) - Phone Fax</p><p>Street, PO Box (If different from Business Address)</p><p>City State Zip Financial Director</p><p>Name E-mail ( ) - ( ) - Phone Fax</p><p>Street, PO Box (If different from Business Address)</p><p>City State Zip TERMS AND CONDITIONS: It is understood and agreed that A. The Applicant accepts the terms and conditions under which this Multi-Year Request for Proposals (RFP) has been issued; B. Funds awarded as a result of this request are to be expended for the purposes set forth herein and the Applicant will provide contracted services in accordance with all contract provisions, applicable laws, regulations, policies and procedures of AAANM, Michigan Office of Services to the Aging (OSA), the Administration on Aging, and the U.S. Department of Health and Human Services, where applicable; C. Awards are subject to the availability of funds from OSA; D. Terms and conditions of this application are not binding on either AAANM or the Applicant until such time that both parties sign the FY 2014-2016 Multi-Year Contract for Aging Services and Notice of Contract Award (NCA).</p><p>Signature of Authorized Official Typed Name/Title Date Proposed Funding, Units & Clients for FY 2014 Aging Services Contract (Refer to 2014 Funding Allocation document for Available Funding by Geographic Service Area) Services for Which Funding is Requested Amount Requested Proposed Units (Unit Measure) Proposed Clients Hours Participant Adult Day Services $ Attended One-Way Trips to & from Adult Day Services Transportation $ Adult Day Congregate Meals $ Eligible Meals Hours Caregiver </p><p>Disease Prevention/Health Promotion Attended Workshop $ (Creating Confident Caregivers Program) Hours Used by Respite </p><p>Participant Disease Prevention/Health Promotion Hours Participant $ (Personal Action Toward Health Program) Attended Workshop Home Delivered Meals $ Eligible Meals Hours Service Provided </p><p> by Caregiver Kinship Caregiver Support & Supplemental Services $ $100 Portion of Goods/</p><p>Services Purchased Legal Assistance $ Hours Staff Time Long-Term Care Ombudsman/ $ Hours Staff Time Elder Abuse Prevention</p><p>Geographical Area to Serve (if more than a Proposed Clients Proposed Units single county) List counties separately.</p>