Opportunity Board / Dementia Care Excellence Collaborative / Letter of Support

Letter of Support

Fill in the following information to sign up to participate in: Dementia Care Excellence Collaborative — National Council of Certified Dementia Practitioners (NCCDP)

1. Your facility

CMS Certification Number (CCN) * — enter it first and we’ll pull your facility’s details from the CMS databaseFacility name * (the name your facility operates under, please change if different from the CMS record)Street address *City *State *ZIP *Bed count (some projects require it in the letter)

2. Your contact information

Your name *Title *Email *Facility phone (appears in the letter)

3. Review your letter

[Facility Name]

[STREET ADDRESS]

[CITY], [STATE] [ZIP]

Title: [Title]

RE: Letter of Support for Dementia Care Excellence Collaborative

This letter confirms [Facility Name]'s commitment to participate in the above-referenced Civil Money Penalty Reinvestment Program.

Project Details:

Project Title: Dementia Care Excellence Collaborative
Project Timeframe: February 1, 2027 - January 31, 2030
Nursing Home CMS Certification Number (CCN): [CCN]

Acknowledgment:

We acknowledge that this funding request will count against our nursing home's maximum cap for the category in which it is designated and commit to participating in the project for its entire duration. During this period, we acknowledge that the funding allocation remains in place regardless of organizational changes and other non-extenuating circumstances.

Additionally, we understand the project determination review process may take approximately 90 days, and we will maintain our commitment to this application during the review period.

Authorized Signature:

[Signer Name], [Title]Name and Title of Authorized Individual

/s/ [Signer Name]Signature

September 10, 2026Date

Signed electronically by [Signer Name] on September 10, 2026. The signer attests that they are authorized to provide this letter of support on behalf of [Facility Name].

4. Sign and send

Type your full legal name to sign *

I attest that I am authorized to provide this letter of support on behalf of my facility, that the information provided is accurate, and that typing my name above constitutes my electronic signature.

The signed PDF is emailed to the project administrator with a copy to you.