? Yes ? No 11. If Yes, List Cost to Each Agency and Name of Agency: Cost: $______________________ Agency: _________________________________________________ Cost: $______________________ Agency: _________________________________________________ 12. Is Any Insurance Paying Part of Contract? ? Yes ? No 13. If Yes, List Amount Paid and Name of Insurance Company: $ _____________________ 14. Certifying Signature:_______________________________________ _________________________ ESE Administrator or Designee Date Signed REPORT OF RESIDENTIAL CONTRACT TERMINATION 1. Date of Termination: ____________________________________ 2. FTE Count(s) Used During the Contract Period: ? October ? February 3. ...
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