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Appendix B
Recommended Consumer Contribution Schedule
NC Division of Aging
and Adult Services
Recommended Contribution Schedule
Based on the 2013 US
Poverty Guidelines
Service Recipients Name:
Service #1 Rate$ Service
#2 Rate $
Service #3
Rate $
| %
of Poverty |
Monthly
Income of: |
Suggested
Percentage of the Cost of Service |
Recommended
Contribution Amount per Unit of Service |
| Individual |
Couple |
Service #1 |
Service #2 |
Service #3 |
| 100% |
$958
- $1,196 |
$1,293
- $1,615 |
10% |
|
|
|
| 125% |
$1,197
$1,435 |
$1,616
$1,938 |
20% |
|
|
|
| 150% |
$1,436
$1,675 |
$1,939 $2,261 |
30% |
|
|
|
| 175% |
$1,676
- $1,914 |
$2,262
– $2,584 |
40% |
|
|
|
| 200% |
$1,915
- $2,153 |
$2,585
- $2,907 |
50% |
|
|
|
| 225% |
$2,154
- $2,393 |
$2,908
- $3,230 |
60% |
|
|
|
| 250% |
$2,394
$2,632 |
$3,231
$3,553 |
70% |
|
|
|
| 275% |
$2,633
$2,872 |
$3,554
$3,877 |
80% |
|
|
|
| 300% |
$2,873
$3,350 |
$3,878
$4,523 |
90% |
|
|
|
| 350% |
$3,351
-- above |
$4,524
-- above |
100% |
|
|
|
The Recommended Consumer Contribution
Schedule may only be shared with service recipients who are
above poverty and receive a Type I service(s). * Voluntary contributions
made toward the cost of services received are not tax deductible.
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