Signature Date PLEASE INITIAL PAGE 2 Please retain a photocopy of this form for your own records. Terms and Conditions on Reverse Side TERMS AND CONDITIONS
Witness Signature 4. PARENT/GUARDIAN CONSENT: (for applicants under 18 years) – I hereby certify and decree that all the information contained in the declarations above is true and accurate Print Name:................................................................... Signature …………………………………………....……... Relationship to applicant ……………………………… Phone Contact ……………………................................... Address …………………………………………………………………….....................................................................
Student Signature By signing this contract, Resident agrees to pay the contract amount (room, board and association fees) in accordance with Addendum B: Rate and Payment Schedule. Resident may pay the full amount due prior to the due date, at the Resident’s election.
Contract Signature If the Original Form of Contract is not returned to the Contract Officer (as identified in Section 4) duly completed, signed and dated on behalf of the Supplier within 30 days of the date of signature on behalf of DFID, DFID will be entitled, at its sole discretion, to declare this Contract void. No payment will be made to the Supplier under this Contract until a copy of the Form of Contract, signed on behalf of the Supplier, is returned to the Contract Officer.
Preparer’s Signature The person completing the DBE commitment form on behalf of the consultant’s firm must sign their name.
Vendor Agreement Signature Form (Part 1)
AGREEMENT SIGNATURES By signing below, both parties agree to the terms and conditions of this Agreement. Please acknowledge acceptance of this document and terms by returning a signed copy within seven (7) days of issuing. If a signed copy is not returned within seven (7) days and you are attending service, Fighting Chance will deem this to be acceptance of the document. If signed by Xxx XxxXxxxxxxX: Signature of Participant: Date: If signed by Person Responsible: I confirm that this Agreement has been explained to the individual receiving the services and that they agree to the terms. I further confirm that I have authority to sign on their behalf. Signature of Person Responsible: Date: SignaĒure on behalf of FighĒing Chance: Signature of Person(s) responsible: Date: Name: Appendix 1 Key Contact Details Participant’s Name Participant’s Email Participant’s Phone Participant’s Address Person(s) responsible’s Name Person(s) responsible Relationship to Participant Person(s) responsible’s Email Person(s) responsible’s Phone Support Coordinator (where applicable) Support Coordinator’s Name Support Coordinator’s Email Support Coordinator’s Phone Shared Living/Supported Accommodation/Group Home (if applicable) House Manager’s Name House Manager’s Email House Manager’s Phone Additional Contacts (if applicable) Role Contact’s Name Contact’s Email Contact’s Phone Appendix 2 NDIS Claiming Preferences Fighting Chance supports NDIS participants who are NDIA-Managed, Self-Managed or Plan Managed. To invoice and bill you correctly, it is important you keep us updated with your plan management preferences, and let us know ongoing if your status changes. For the purposes of services delivered by Fighting Chance, your NDIS plan is: (please tick) ☐ NDIA-MANAGED You understand that Fighting Chance will claim directly through the NDIA portal if your funding for Fighting Chance is NDIA-managed, so you will not receive any direct request for payment from us. To ensure that you do not get a text from the NDIA to approve each claim weekly, endorse Fighting Chance as a ‘My Provider’ for automatic payment processing. Instructions can be found at xxxxxxxxxxxxx.xxx.xx/xxxx/ or you can contact the Fighting Chance My Provider Endorsement Helpdesk on (00) 0000 0000 or xxxxxxxxxxxxxxx@xxxxxxxxxxxxx.xxx.xx ☐ (Optional) Please supply me, by email, with monthly Statements of Account to: ☐ SELF-MANAGED ☐ I am self-managed and would like to be invoiced for services once a week. Please email invoices to: Please see Appendix 3 for Self-Management Payment Options. ☐ PLAN-MANAGED Please send invoices to my plan manager: Plan management organisatio Contact Name Email Address Phone number ☐ OTHER FUNDING (eg. self-funded, iCare or other insurance funding) Please email invoices to: Appendix 3 Self-Managed Payment Options Participants who are self-managed have a number of payment options with Fighting Chance: ☐ DIRECT DEPOSIT (preferred option) Payment of Fighting Chance invoices can be made by Electronic Funds Transfer (EFT) through your bank. Fighting Chance’s bank account details are as follows: Bank: Commonwealth Bank of Australia Account Name: Fighting Chance Australia Ltd BSB: 062-438 Account Number: 00000000 To ensure all payments are correctly allocated to your account, please include the full invoice number in the reference field. ☐ CREDIT CARD Payments can be made by credit card by clicking the ‘pay by credit card’ link included on the invoice. Please note that a service fee for this option will be imposed. ☐ PAYPAL Payment of your invoices can also be made via our PayPal account. To make payment via PayPal, please access the following link: xxxxx://xxxxxx.xx/FightingChanceAus?locale.x=en_AU To ensure your payment is correctly allocated, please enter the full invoice number in the reference field. Appendix 4 Non Face to Face Time Breakdown - Jigsaw Standard Non Face-to-Face Supports Delivered to every Jigsaw Participant daily, weekly, annually Writing the Board (i.e. preparing and writing up each person’s individualised program for the following day). Reviewing Trainee records/journal notes/medical or other key information to be able to best support the person during their day. Parent/Guardian/Carer Updates, i.e. emails, phone calls. Pre- and post-shift sta briefings. Zone setup (setting up workstations, boxes, visuals and group training areas) Resource development to support each Trainee to progress towards their employment goals (adapting training resources, creating visual aids and cheat sheets, etc). Research/Coordination to implement support strategies (disability, behavioural and learning strategies). Family reviews and the development of training plans (planning, delivery and follow up). Planning social events and extra curricular training (e.g. TAFE). Standard NDIS Annual Support Review Letter. Standard Ǫuarterly Reports - Upon Request. Complex Non Face-to-Face Supports - Delivered to Jigsaw Participants with High Intensity Support Needs (in addition to supports outlined in Standard) Allied health meetings, phone calls, correspondence. Specialist/additional sta training (internal or external), i.e. BSP implementation training. Creation of additional/detailed social stories/visuals. Data collection requested by behaviour therapists. Incident follow up or crisis meetings (seperate to regular family updates or regular allied health meetings). Development/review/discussion of medication forms/transfer plans/mealtime assistance plans etc. Detailed and regular sta training on individual complex behaviour/medical/transfer/mealtime support plans. Extended daily pre-brief and debrief. Additional Non Face-to-Face Supports - billed separately upon request Detailed NDIS Review Letters One-o engagement or training with Allied Health. Detailed Ǫuarterly Reports.
Employee Signature Employee ID: Telephone No: Employee Address: Work Location:
OFFICER SIGNATURE OFFICER NAME: TITLE Exhibit 2a This exhibit contains three versions of the loss share calculation for foreclosure, plus explanatory notes. Exhibit 2a(1) CALCULATION OF FORECLOSURE LOSS Foreclosure Occurred Prior to Loss Share Agreement 1 Shared-Loss Month May-09 2 Loan no: 364574 3 REO # 621 4 Foreclosure date 12/18/08 5 Liquidation date 4/12/09 6 Note Interest rate 8.100% 7 Most recent BPO 228,000 8 Most recent BPO date 1/21/09 Foreclosure Loss calculation 9 Book value at date of Loss Share agreement 244,900 Accrued interest, limited to 90 days or days from failure 10 to sale, whichever is less 3,306 11 Costs incurred after Loss Share agreement in place: 12 Attorney's fees 0 Foreclosure costs, including title search, filing fees, 13 advertising, etc. 0 14 Property protection costs, maint. and repairs 6,500 15 Tax and insurance advances 0 Other Advances 16 Appraisal/Broker's Price Opinion fees 0 17 Inspections 0 18 Other 0 19 Gross balance recoverable by Purchaser 254,706 Cash Recoveries: 20 Net liquidation proceeds (from HUD-1 settl stmt) 219,400 21 Hazard Insurance proceeds 0 22 Mortgage Insurance proceeds 0 23 T & I escrow account balances, if positive 0 24 Other credits, if any (itemize) 0 25 Total Cash Recovery 219,400 26 Loss Amount 35,306 Exhibit 2a(2)
EFFECTIVE DATE AND SIGNATURE This MOU shall be effective upon the signature of authorized officials from Party A and Party B. It shall be in force from (Date to be finalized with Lease-Up) to (Date to be finalized with Lease-Up). Parties A and B indicate agreement with this MOU by their signatures below. Party A Party B By: By: Title: Title: Signed: Signed: Date: Date:
