Common use of Environmental Tobacco Smoke Clause in Contracts

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Navigator Grant Monthly Report Month and Year (e.g., Oct 2013, enter as 10/13) Navigator Grantee Organization: Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ Phone Number: Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. APPENDIX I – REQUIRED FORMS DEPARTMENT OF VERMONT HEALTH ACCESS Date of Request: Original Grantee Contractor Name: Grantee Contractor #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:$

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date The Contractor shall install, configure and maintain an automated call distributor telephone system and will establish and maintain a sufficient number of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope phone lines, IVR and Musak ports to accommodate peak call volumes without delivering a busy signal or silence, and to meet the performance standards of Subcontracted Services: Is any portion this contract. The telephone system will have the ability to direct incoming calls to specific queues and assign calls to available staff within each queue and/or provide call forwarding as necessary or directed by the State. On site, in the moment management of call queues by a dedicated Workforce Planner is required. Queue definition and overflow protocols will be approved by the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:State.

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:$

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number: Comments: Approval: Title: Date:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement Contract #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:$

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: APPENDIX I – REQUIRED FORMS Original Grantee Contractor Name: Grantee Contract #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ : Phone Number: Comments: Approval: Title: Date:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date INVOICE Address: State: Zip Code: Date: Contract #: Contractor Billing Contact: Phone #: Signature: Dates of RequestService Description of Deliverables/Work Performed Contractor Amount TOTAL: Remittance Address: Xxxx to Address: Xxxxxxx Xxxxxxx Department of Vermont Health Access 000 Xxxxxxxxx Xxxx, Xxxxx 000 Xxxxxxxxx, Xxxxxxx 00000-0000 Xxxxxxx.Xxxxxxx@xxxxx.xx.xx DVHA BO USE: *INVOICE PAYMENTS ARE NET00 TERMS, UNLESS STATED OTHERWISE* Original Grantee Contractor Name: Grantee Contract #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ Phone Number: Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ Phone Number: Comments: Approval: Title: Date:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number:: Comments: Approval: Title: Date: Cost: Funding Source: [CFDA # if different than original] Budget Approval (Initials)

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number:: Comments: Approval: Title: Date: Agreement #00000-0000-00 Date: Start 11/1/14 (Awardee to complete) Reconciliation: Bi-State Primary Care Current Month Award $ : Spending Cumulative Spend to date: Award Balance Travel $704 704.00 Meetings $250 250.00 Supplies $3,696 3,696.00 Professional Services $16,750 - 16,750.00 Miscellaneous - Beneficiary Engagement $0 - Contractual - Pharos Innovations, LLC (telemonitoring) $298,000 298,000.00 Contractual - Other IT, etc. $75,000 - 75,000.00 Contractual - Patient Experience Surveying $14,000 - 14,000.00 Contractual - Triage Care Coordination $110,000 110,000.00 Facility $15,000 15,000.00 Indirect $0 - Totals : $533,400 - - 533,400.00

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees entity Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Contractor Billing Contact: Phone #: Date (if applicable) Description of Deliverables/Work Performed Amount Signature: Remittance Address: Xxxx to: Business Office Department of Vermont Health Access 000 Xxxxxxxxx Xxxx Xxxxxxxxx, XX 00000 Date of Request: Original Grantee Name: Address: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ Phone Number: Comments: Approval: Title: Date: a. Party understands and acknowledges responsibility, if applicable, for compliance with State tax laws, including income tax withholding for employees performing services within the State, payment of use tax on property used within the State, corporate and/or personal income tax on income earned within the State. b. Party certifies under the pains and penalties of perjury that, as of the date the Agreement is signed, the Party is in good standing with respect to, or in full compliance with, a plan to pay any and all taxes due the State of Vermont. c. Party understands that final payment under this Agreement may be withheld if the Commissioner of Taxes determines that the Party is not in good standing with respect to or in full compliance with a plan to pay any and all taxes due to the State of Vermont. d. Party also understands the State may set off taxes (and related penalties, interest and fees) due to the State of Vermont, but only if the Party has failed to make an appeal within the time allowed by law, or an appeal has been taken and finally determined and the Party has no further legal recourse to contest the amounts due. a. is not under any obligation to pay child support; or b. is under such an obligation and is in good standing with respect to that obligation; or c. has agreed to a payment plan with the Vermont Office of Child Support Services and is in full compliance with that plan. Party makes this statement with regard to support owed to any and all children residing in Vermont. In addition, if the Party is a resident of Vermont, Party makes this statement with regard to support owed to any and all children residing in any other state or territory of the United States.

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Subrecipients are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of RequestSUBRECIPIENT’S NAME & ADDRESS:‌‌ ATTACHMENT H DEPARTMENT OF VERMONT HEALTH ACCESS FINANCIAL REPORT & REQUEST FOR FUNDS CONTACT PERSON: Original Grantee Name: Grantee DAY PHONE #: Address: Phone Number: Contact Person: Agreement FEDERAL ID #: SignatureGRANT#: Subcontractor Name03410- _ PERIOD COVERED: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United StatesTO IS THIS A FINAL REPORT? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:AWARDED AMOUNT $

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Grantee Billing Contact: Phone #: Signature: _ Date (if applicable) Description of Deliverables/Work Performed Amount Remittance Address: Xxxx to: Business Office Department of Vermont Health Access 000 Xxxxxxxxx Xxxx Xxxxxxxxx, XX 00000 Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: _ Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt.) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number:: Comments: _ _ Approval: Title: Date: _

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date INVOICE Address: State: Zip Code: Date: Contract #: Contractor Billing Contact: Phone #: Signature: Dates of RequestService Task # Description of Deliverables/Work Performed Contractor Amount TOTAL: Remittance Address: Xxxx to Address: Xxxxxxx Xxxxxxx Department of Vermont Health Access 000 Xxxxxxxxx Xxxx, Xxxxx 000 Xxxxxxxxx, Xxxxxxx 00000-0000 Xxxxxxx.Xxxxxxx@xxxxx.xx.xx DVHA BO USE: *INVOICE PAYMENTS ARE NET30 TERMS, UNLESS STATED OTHERWISE* Original Grantee Contractor Name: Grantee Contract #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ Phone Number: Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Contractor Name: Grantee Contract #: Address: Phone Number: Contact Person: Agreement #: Signature: :________ _ Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ Phone Number:: Comments: _____ _ Approval: _____ _ Title: _ Date: __

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number: Business Office Review Comments: Federally Qualified Health Center (FQHC)/Rural Health Center (RHC) ADUSTMENT‌ 1. The method of the adjustment is as follows: 2. Using historic cost per encounter data from 2010-2012 either from settled or filed cost reports, a Cumulative Average Growth Rate (CAGR) will be calculated for each FQHC and RHC. The CAGR will be used to adjust the most recent cost per encounter to the 2014 Performance Year. This cost per encounter will be substituted in both the actual and expected cost calculations in lieu of the Medicaid capped amount. 3. Currently available historic, CAGR and estimated 2014 cost per encounter data is below. Note however, the final adjustment will be done using the most recently available data as of December 31 in the performance year.

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number: Approval: Title: Date:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Contractor Name: Grantee Contractor #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:$

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Contractor/Grantee Name: Grantee Contract/Grant #: _____ _ Address: Phone Number: Contact Person: Agreement #: Signature: :________ _ Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ _ Phone Number:: Comments Approval: Title: _ Date: _

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:$

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or MedicaidMed icaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Grantee Billing Contact: Phone #: Signature: _ Date (if applicable) Description of Deliverables/Work Performed Amount Remittance Address: Xxxx to: Business Office Department of Vermont Health Access 000 Xxxxxxxxx Xxxx Xxxxxxxxx, XX 00000 Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: _ Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number:: Comments: _ _ Approval: Title: Date: _

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Contractor Billing Contact: Phone #: _ Signature: _ Date (if applicable) Description of Deliverables/Work Performed Amount Remittance Address: Xxxx to: Business Office Department of Vermont Health Access 000 Xxxxxxxxx Xxxx Xxxxxxxxx, XX 00000 Date of Request: Original Grantee Contractor Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: _ Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number:: Comments: _ _ Approval: Title: Date: _ a. Party understands and acknowledges responsibility, if applicable, for compliance with State tax laws, including income tax withholding for employees performing services within the State, payment of use tax on property used within the State, corporate and/or personal income tax on income earned within the State. b. Party certifies under the pains and penalties of perjury that, as of the date the Agreement is signed, the Party is in good standing with respect to, or in full compliance with, a plan to pay any and all taxes due the State of Vermont. c. Party understands that final payment under this Agreement may be withheld if the Commissioner of Taxes determines that the Party is not in good standing with respect to or in full compliance with a plan to pay any and all taxes due to the State of Vermont. d. Party also understands the State may set off taxes (and related penalties, interest and fees) due to the State of Vermont, but only if the Party has failed to make an appeal within the time allowed by law, or an appeal has been taken and finally determined and the Party has no further legal recourse to contest the amounts due. a. is not under any obligation to pay child support; or b. is under such an obligation and is in good standing with respect to that obligation; or c. has agreed to a payment plan with the Vermont Office of Child Support Services and is in full compliance with that plan. Party makes this statement with regard to support owed to any and all children residing in Vermont. In addition, if the Party is a resident of Vermont, Party makes this statement with regard to support owed to any and all children residing in any other state or territory of the United States.

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood chi ldhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees entity Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Contractor Billing Contact: Phone #: Signature: Date (if applicable) Description of RequestDeliverables/Work Performed Amount Remittance Address: Xxxx to: Business Office Department of Vermont Health Access NOB 1 South, 000 Xxxxx Xxxxx Xxxxxxxxx, XX 00000 Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: _ Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number: Business Office Review Comments: _ Approval: Title: Date: a. Party understands and acknowledges responsibility, if applicable, for compliance with State tax laws, including income tax withholding for employees performing services within the State, payment of use tax on property used within the State, corporate and/or personal income tax on income earned within the State. b. Party certifies under the pains and penalties of perjury that, as of the date the Agreement is signed, the Party is in good standing with respect to, or in full compliance with, a plan to pay any and all taxes due the State of Vermont. c. Party understands that final payment under this Agreement may be withheld if the Commissioner of Taxes determines that the Party is not in good standing with respect to or in full compliance with a plan to pay any and all taxes due to the State of Vermont. d. Party also understands the State may set off taxes (and related penalties, interest and fees) due to the State of Vermont, but only if the Party has failed to make an appeal within the time allowed by law, or an appeal has been taken and finally determined and the Party has no further legal recourse to contest the amounts due. a. is not under any obligation to pay child support; or b. is under such an obligation and is in good standing with respect to that obligation; or c. has agreed to a payment plan with the Vermont Office of Child Support Services and is in full compliance with that plan. Party makes this statement with regard to support owed to any and all children residing in Vermont. In addition, if the Party is a resident of Vermont, Party makes this statement with regard to support owed to any and all children residing in any other state or territory of the United States.

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonBusiness Lead: Signature:______________________________ Phone Number:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: _ Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:$

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of RequestAPPENDIX I – REQUIRED FORMS DEPARTMENT OF VERMONT HEALTH ACCESS CONTRACTOR’S NAME& ADDRESS: Original Grantee NameCONTACT PERSON: Grantee DAY PHONE #: Address: Phone Number: Contact Person: Agreement FEDERAL ID #: SignaturePERIOD COVERED: Subcontractor NameTO GRANT#: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United StatesIS THIS A FINAL REPORT? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:AWARDED AMOUNT $

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Contractor Name: Grantee Contract #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ Phone Number: Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. APPENDIX I – REQUIRED FORMS DEPARTMENT OF VERMONT HEALTH ACCESS Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number:: Comments: Approval: Title: Date: Healthfirst Practices Participating in Chart Review Grant 1. Alder Brook Family Health 2. Brookside Family Health Center 3. Office of Xxxxx Xxxxxxx, M.D. 4. Charlotte Family Health Center 5. Office of Xxxxxxxxxxx X. Xxxxxx, M.D.

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Contractor Name: Grantee Contractor #: Address: Phone Number: Contact Person: Agreement #: Signature: :________ _ Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ Phone Number: Comments: _____ _ Approval: _____ _ Title: _ Date: __ PROJECT CHANGE REQUEST FORM In accordance with Attachment A, Section E.3.ii, Change Management Process, this Project Change Request Form will be used by the Executive Management Team (EMT) to review and approve changes to the budget, schedule, or scope of work of this Agreement. To the extent that budget increases or significant scope changes would be required, those changes would be subject t o a formal amendment to this Agreement executed by VITL and the State Department of Vermont Health Access (DVHA). This document must be signed by both parties before being considered in effect. Change Request Name: Date submitted: Priority: H M L Requested by: Assessed by: Change Request ID: Detail (Description of Proposed Change): Reason for Change (Benefits): Implications of Not Making This Change: Related Project Name: Cost Impact: Schedule Impact: Resource Impact: Other Implications: Overall Assessment/Recommendation: Requires Amendment to Agreement: YES NO Executive Director, VT Blueprint for Health: Date: CEO, VITL: Date: 1. Change: Authorized 2. Change: Deferred 3. Change: Disapproved Explain if Deferred or Disapproved:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:$

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Contractor Name: Grantee Contract #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ : Phone Number:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee Contract #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact PersonProgram Manager: Signature:______________________________ : Phone Number: Business Office Review Comments: Approval: Title: Date: 1. The method of the adjustment is as follows: 2. Using historic cost per encounter data from 2010-2012 either from settled or filed cost reports, a Cumulative Average Growth Rate (CAGR) will be calculated for each FQHC and RHC. The CAGR will be used to adjust the most recent cost per encounter to the 2014 Performance Year. This cost per encounter will be substituted in both the actual and expected cost calculations in lieu of the Medicaid capped amount. 3. Currently available historic, CAGR and estimated 2014 cost per encounter data is below. Note however, the final adjustment will be done using the most recently available data as of December 31 in the performance year.

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: :________ _ Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number:$