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SPECIAL TERMS AND CONDITIONS 1. Definitions a. "Commingle" is the act of mixing the funds and/or Long-Term Payables for one program with the funds of another program. b. "Documentation of Funds form" (DOF) is a form provided to the County each year by DSHS on which the County records qualifying previous year expenditures from which OSHS can appraise and evaluate the amount of the existing Long-Term Payable or appropriate adjustments. c. "Long-Term Payable" means funds provided by DSHS to the County in anticipation of specific client services provided by the County. The County shall not be allowed to retain any overage of the Long-Term Payable funds if the County does not actually provide the anticipated services during the given timeframe. Long-Term Payable funds are to be reconciled by April 30 of each year and any funds not fully utilized shall be refunded to DSHS by May 31 of each year. 2. Purpose a . It is the purpose of this Agreement to specify the procedure by which DSHS will assess and , if necessary, adjust the Long-Term Payable it provides to the County. b. Funds to support contracts for the following DSHS programs may be included in a Long-Term Payable: Developmental Disabilities Administration (DDA) and/or Aging and Long-Term Support Administration (AL TSA). 3. Statement of Work a. County Responsibilities (1) The County s hall su bmit to DSHS, on forms provided by DS HS and by a date determine d by DSHS, a com pleted Do cume·ntation of Funds form (OOF) f rom which DSHS shall assess whether or not an adjustment to the amount of the Long-Term Payable provided to the County is warranted. (2) The County shall exclude all amounts related to its Prepaid Inpatient Health Plan expenditures from its DO F. (3) The County shall repay to OSHS all of the Long-Term Payable funds received from DSHS that exceed the amount that DSHS determines is warranted. Repayment requirements shall be based upon DSHS assessment of the most recent annual DOF submitted by the County to DSHS. Any long-Term Payable funds not fully utilized by the County , as determined by DSHS through the OOF process, shall be refunded to OSHS by May 31 of each year. (4) The County shall only utilize long-Term Payable funds for the DSHS program or service for which the funds were originally deSignated. Long-Term Payable funds may not be commingled between or among programs or services . (5) Any Interest the County earns on the Long-Term Payable funds shall only be utilized for the DSHS programs or services for which the funds were originally designated. Long-Term Payable interest shall not be used for programs or services unrelated to the client services anticipated by this Agreement. (6) The County shall record the Long-Term Payables in its financial records. DSHS Central Contract Services 8030CS County Long-Term Payable (3·28-2017) Page 2