DADS CDS Attendant Care Budget by esncQK0

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									Texas Department of                                                                            HCS CDS Budget
Aging and Disability Services                                                                      August 2008




                                   Home and Community Based Services
                                            Consumer Directed Services Budget
                                General Information and Instructions for Use of Workbook

                                THIS PAGE IS NOT CONSIDERED PART OF THE BUDGET

                Enter the appropriate information in the "Blue" cells (the cells with "dashed" lines around
              * them). Be sure the information you enter is accurate, as the budget calculations are based
                on the entries made in these cells.

              * Use the "TAB" key to move between the "Blue" cells. Entries may only be made in the
                "Blue" cells; all other cells are locked.

                You can use the keyboard to move between the pages in the workbook. Press "CTRL" and
              * "Page Down" at the same time to move to the next worksheet; Press "CTRL" and "Page Up"
                at the same time to move to the previous worksheet.


              * Watch for "Pop-Up" information windows for many of the cells. If the "Pop-Up" windows are
                covering the body of the budget, you may "drag and drop" them to a different area.

              * Be sure to read any error messages carefully. They give you instructions on how to correct
                data entry errors.

              * Complete the entire Workbook for each Consumer at the following times (and when required
                by program policy):
                    Initially and at Annual Reassessment
                    Termination of Services
                    Change in Employee
                    Change in Number of Hours Employee Works, Rate of Pay, Bonus, or Benefits
                    Change in Employee Pay Rate or Benefits
                    Change in Reimbursement Rate
                    Change in Administrative Costs
                    Change in Payment Option back to Agency Option
                    Change in Number of Authorized Units for Hourly Services
                    Use of Respite Services
                    Anytime Other Time Required by Program Policy
                Complete the Quarterly Report at least Quarterly (more frequently if required by Program
                Policy)


              * Be sure both the Employer (Consumer or Legal Guardian), Designated Responsible Party (if
                applicable), and the CDS Agency Representative sign Consumer Information & Budget
                Approval Page of the workbook, and that the budget Calculations are listed as "VALID".

              * Submit a copy of the current Budget Workbook to the appropriate Case Manager/Service
                Coordinator initially, annually, and as required by program policy.




                                                                                       Date and Time Created
                                                                                           8/31/2012 1:11 PM
Texas Department of                                                                                                                                HCS CDS Budget
Aging and Disability Services                                                                                                                          August 2008




                                       Home and Community Based Services
                                                  Consumer Directed Services Budget
                                               Consumer Information & Budget Approval

                                                    Consumer Name:

                                 Consumer Medicaid Number:

                                             Consumer's Address:

                          Consumer's City, State, Zip Code:

                            Consumer's Telephone Number:

                                             Waiver Contract Area:

               Does the Consumer Have a Designated Representative (DR) and/or
                                     Legally Authorized Representative (LAR)?

                                                            LAR's Name:
                                                             DR's Name:

        Effective / Coverage Period (This does not guarantee
                                eligibility for the entire period):


                                                                                       Budget Calculations are:                         VALID
       CERTIFICATION: By signature below I acknowledge that all calculations must fall within the allowable budget, and that all budget calculations are
       VALID, as indicated above. I acknowledge these budget calculations are not exact, and may need adjustment throughout the budget period. I also
       acknowledge receipt of a copy of the CDS Budget. I agree to remain within the boundaries of the budget set forth. I understand that failure to
       follow this budget may result in removal from the CDS Option and I accept personal liability for expenses that may be incurred due to my failure to
       follow the budget or program requirements. The budget does not imply eligibility for the entire budget period.




       Employer (Consumer or Legally Authorized Representative)                                                               Date




       Designated Responsible Party (If Applicable)                                                                           Date




       CDS Agency Representative                                                                                              Date




                                                                                                                                             Date and Time Created:
                                                                                                                                                  8/31/2012 1:11 PM
Texas Department of                                                                     HCS CDS Budget
Aging and Disability Services                                                               August 2008




                                Home and Community Based Services
                                      Consumer Directed Services Budget
                                                   Notes

                                       0                                                  0
                                 Consumer Name                                 Medicaid Number

                                           Coverage Period From:   1/0/1900   To:       1/0/1900




                                                                                    Date and Time Created
                                                                                        8/31/2012 1:11 PM
Texas Department of                                                                                HCS CDS Budget
Aging and Disability Services                                                                          August 2008




                                Home and Community Based Services
                                          Consumer Directed Services Budget



                                      0                                                        0
                                Consumer Name                                        Medicaid Number

                                           Coverage Period From:   1/0/1900        To:        1/0/1900



                                    Total Annual CDS Budget              $0.00




                                                Service                Supported Home Living
          Annual Authorized Supported Home Living Hours
          Weekly Authorized Supported Home Living Hours                           0.00
                                                   Rate                          $23.49
                     Total Supported Home Living Dollars                         $0.00

                                                     Service                  Hourly Respite
                      Annual Authorized Hourly Respite Hours
                      Weekly Authorized Hourly Respite Hours                      0.00
                                                        Rate                     $13.52
                                 Total Hourly Respite Dollars                    $0.00

                                                      Service                 Daily Respite
                         Annual Authorized Daily Respite Units
                         Weekly Authorized Daily Respite Units                     0.00
                                                         Rate                    $135.20
                                   Total Daily Respite Dollars                    $0.00

                                                       Service                   Dental
                          Annual Authorized Daily Respite Units

                                                       Service                Adaptive Aids
                          Annual Authorized Daily Respite Units

                                                       Service        Minor Home Modifications
                          Annual Authorized Daily Respite Units




                                                                                              Date and Time Created
                                                                                                  8/31/2012 1:11 PM
       Texas Department of                                                                                                  HCS CDS Budget
       Aging and Disability Services                                                                                            August 2008




                           Home and Community Based Services
                                   Consumer Directed Services Budget
                             Employer Support Services & Non-Taxable Costs

                                0                                                                    0
                            Consumer Name                                                     Medicaid Number

                                        Coverage Period From:           1/0/1900        To:         1/0/1900


                                                               Total Annual CDS Budget
                           (including Dental, Adaptive Aids, and Minor Home Modifications) :               $0.00

                       Amount Available for all Estimated
                       Employer Support Services Costs                                                     $0.00
             (excludes Dental, Adaptive Aids, and Minor Home Modifications):

                      Estimated Employer Related Support Services Purchases
               Maximum Amount Available for Employer Related Support Services Purchases:                        $0.00
                                                                      Amount:                               Comments:
Advertising
Equipment & Supplies
Copies & Mailing
Criminal History Check
Other - Specify
Other - Specify
                   Total Estimated Employer Related Support Services Purchases:                                 $0.00

                              Estimated Support Consultation Services Costs
                                               Amount of ESS Available for Support Consultation:               $0.00
                                                   Available Support Consultation Services Hours:               0.00
                                       Support Consultation Services Hours Authorized by the IDT:
                                              Support Consultation Services Funded through ESS:                 $0.00
           Payment for Support Consultation Services above the 10% (if required by the IDT):                   $0.00
                                                      Total Support Consultation Services Costs:               $0.00
                               Total Costs for ESS and Support Consultation Services:                          $0.00


                          Non-Taxable Employee Compensation Costs
                                                 Amount Available for Employee Compensation Costs: $0.00
                                                                              Amount:                       Comments:
Health Insurance Premium(s)
Worker's comp or liability insurance
Other - Specify
Other - Specify
                               Total Estimated Non-Taxable Compensation Costs:                                 $0.00

               Total Spent for ESS and Non-Taxable Costs                                                      $0.00

    Funds Available for Taxable Compensation Costs                                                     $0.00




                                                                                                                        Date and Time Created
                                                                                                                            8/31/2012 1:11 PM
      Texas Department of                                                                                                                                HCS CDS Budget
      Aging and Disability Services                                                                                                                          August 2008




                                                Home and Community Based Services
                                                          Consumer Directed Services Budget

                                                      Taxable Wage and Compensation Costs
                                0                                                                                        0
                          Consumer Name                                                                           Medicaid Number
                                         Coverage Period From:            1/0/1900           To:               1/0/1900

                                                                    Available Amounts
                     Total Available for Taxable Compensation:        $0.00
                                                                                           Dollars Left in Budget:                    $0.00
                                      Total Taxable Compensation:     $0.00


                                               Taxable Wage and Compensation Validation
                      Within Total Budget for Consumer?                                                                   Yes

                                         Employee Hours, Pay Rates and Other Compensation
1                                                                             Weeks        S.U.T.A.    Total Annual
     Employee Name                                    Begin Date     End Date Employed       Rate        Wages      Annual Taxes    Annual Total
                                                                                    0.00                      $0.00         $0.00            $0.00


                                                                     Hours per
    Hourly Pay                                                        Week     Pay Rate     Weeks      OT Pay Rate     Wages
                                                       SHL                                 0.00                       $0.00
                                              Hourly Respite                               0.00                       $0.00
                                               Daily Respite                               0.00                       $0.00
                                                   Overtime                                                           $0.00
                              NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                        more than the weekly authorized units.

                                                                               Number of
    Other Compensation                                                Amount   Payments     Wages
                                                        Bonuses                                $0.00
                                                   Paid Holidays                               $0.00
                                                    Vacation Pay                               $0.00
                                                      Sick Leave                               $0.00
                                                   Other -Specify                              $0.00




                                                                                                                                                     Date and Time Created
                                                                                                                                                         8/31/2012 1:11 PM
      Texas Department of                                                                                                                             HCS CDS Budget
      Aging and Disability Services                                                                                                                       August 2008




                                            Home and Community Based Services
                                                      Consumer Directed Services Budget

                                                   Taxable Wage and Compensation Costs
                                0                                                                                    0
                          Consumer Name                                                                       Medicaid Number
                                      Coverage Period From:            1/0/1900           To:               1/0/1900

                                                                 Available Amounts
2                                                                          Weeks        S.U.T.A.   Total Annual
     Employee Name                                Begin Date      End Date Employed       Rate       Wages      Annual Taxes     Annual Total
                                                                                 0.00                     $0.00         $0.00             $0.00


                                                                  Hours per
    Hourly Pay                                                     Week     Pay Rate  Weeks     OT Pay Rate      Wages
                                                       SHL                                 0.00                       $0.00
                                              Hourly Respite                               0.00                       $0.00
                                               Daily Respite                               0.00                       $0.00
                                                   Overtime                                                           $0.00
                              NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                        more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments    Wages
                                                     Bonuses                               $0.00
                                                Paid Holidays                              $0.00
                                                 Vacation Pay                              $0.00
                                                   Sick Leave                              $0.00
                                                Other -Specify                             $0.00


3                                                                          Weeks        S.U.T.A.   Total Annual
     Employee Name                                Begin Date      End Date Employed       Rate       Wages      Annual Taxes     Annual Total
                                                                                 0.00                     $0.00         $0.00             $0.00


                                                                  Hours per
    Hourly Pay                                                     Week     Pay Rate  Weeks     OT Pay Rate      Wages
                                                       SHL                                 0.00                       $0.00
                                              Hourly Respite                               0.00                       $0.00
                                               Daily Respite                               0.00                       $0.00
                                                   Overtime                                                           $0.00
                              NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                        more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments    Wages
                                                     Bonuses                               $0.00
                                                Paid Holidays                              $0.00
                                                 Vacation Pay                              $0.00
                                                   Sick Leave                              $0.00
                                                Other -Specify                             $0.00


4                                                                          Weeks        S.U.T.A.   Total Annual
     Employee Name                                Begin Date      End Date Employed       Rate       Wages      Annual Taxes     Annual Total
                                                                                 0.00                     $0.00         $0.00             $0.00


                                                                  Hours per
    Hourly Pay                                                     Week     Pay Rate  Weeks     OT Pay Rate      Wages
                                                       SHL                                 0.00                       $0.00
                                              Hourly Respite                               0.00                       $0.00
                                               Daily Respite                               0.00                       $0.00
                                                   Overtime                                                           $0.00
                              NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                        more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments    Wages
                                                     Bonuses                               $0.00
                                                Paid Holidays                              $0.00
                                                 Vacation Pay                              $0.00
                                                   Sick Leave                              $0.00
                                                Other -Specify                             $0.00


5                                                                          Weeks        S.U.T.A.   Total Annual
     Employee Name                                Begin Date      End Date Employed       Rate       Wages        Annual Taxes   Annual Total     Date and Time Created
                                                                                                                                                      8/31/2012 1:11 PM
      Texas Department of                                                                                                                            HCS CDS Budget
      Aging and Disability Services                                                                                                                      August 2008




                                            Home and Community Based Services
                                                      Consumer Directed Services Budget

                                                   Taxable Wage and Compensation Costs
                                0                                                                                    0
                          Consumer Name                                                                       Medicaid Number

5                                     Coverage Period From:            1/0/1900           To:              1/0/1900

                                                                              0.00
                                                                 Available Amounts                       $0.00          $0.00           $0.00


                                                                  Hours per
    Hourly Pay                                                     Week     Pay Rate  Weeks     OT Pay Rate      Wages
                                                       SHL                                 0.00                       $0.00
                                              Hourly Respite                               0.00                       $0.00
                                               Daily Respite                               0.00                       $0.00
                                                   Overtime                                                           $0.00
                              NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                        more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments    Wages
                                                     Bonuses                               $0.00
                                                Paid Holidays                              $0.00
                                                 Vacation Pay                              $0.00
                                                   Sick Leave                              $0.00
                                                Other -Specify                             $0.00


6                                                                          Weeks        S.U.T.A.   Total Annual
     Employee Name                                Begin Date      End Date Employed       Rate       Wages      Annual Taxes    Annual Total
                                                                                 0.00                     $0.00         $0.00            $0.00


                                                                  Hours per
    Hourly Pay                                                     Week     Pay Rate  Weeks     OT Pay Rate      Wages
                                                       SHL                                 0.00                       $0.00
                                              Hourly Respite                               0.00                       $0.00
                                               Daily Respite                               0.00                       $0.00
                                                   Overtime                                                           $0.00
                              NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                        more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments    Wages
                                                     Bonuses                               $0.00
                                                Paid Holidays                              $0.00
                                                 Vacation Pay                              $0.00
                                                   Sick Leave                              $0.00
                                                Other -Specify                             $0.00


7                                                                          Weeks        S.U.T.A.   Total Annual
     Employee Name                                Begin Date      End Date Employed       Rate       Wages      Annual Taxes    Annual Total
                                                                                 0.00                     $0.00         $0.00            $0.00


                                                                  Hours per
    Hourly Pay                                                     Week     Pay Rate  Weeks     OT Pay Rate      Wages
                                                       SHL                                 0.00                       $0.00
                                              Hourly Respite                               0.00                       $0.00
                                               Daily Respite                               0.00                       $0.00
                                                   Overtime                                                           $0.00
                              NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                        more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments    Wages
                                                     Bonuses                               $0.00
                                                Paid Holidays                              $0.00
                                                 Vacation Pay                              $0.00
                                                   Sick Leave                              $0.00
                                                Other -Specify                             $0.00


8                                                                          Weeks        S.U.T.A.   Total Annual
     Employee Name                                Begin Date      End Date Employed       Rate       Wages      Annual Taxes    Annual Total
                                                                                 0.00                     $0.00         $0.00            $0.00

                                                                                                                                                 Date and Time Created
                                                                                                                                                     8/31/2012 1:11 PM
       Texas Department of                                                                                                                            HCS CDS Budget
       Aging and Disability Services                                                                                                                      August 2008




                                             Home and Community Based Services
                                                       Consumer Directed Services Budget

                                                    Taxable Wage and Compensation Costs
 8                               0                                                                                    0
                           Consumer Name                                                                       Medicaid Number
                                       Coverage Period From:            1/0/1900           To:              1/0/1900

                                                                   Hours per
                                                                  Available Amounts
     Hourly Pay                                                 Week     Pay Rate      Weeks     OT Pay Rate      Wages
                                                        SHL                                 0.00                       $0.00
                                               Hourly Respite                               0.00                       $0.00
                                                Daily Respite                               0.00                       $0.00
                                                    Overtime                                                           $0.00
                               NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                         more than the weekly authorized units.

                                                                             Number of
     Other Compensation                                             Amount   Payments    Wages
                                                      Bonuses                               $0.00
                                                 Paid Holidays                              $0.00
                                                  Vacation Pay                              $0.00
                                                    Sick Leave                              $0.00
                                                 Other -Specify                             $0.00


 9                                                                          Weeks        S.U.T.A.   Total Annual
      Employee Name                                Begin Date      End Date Employed       Rate       Wages      Annual Taxes    Annual Total
                                                                                  0.00                     $0.00         $0.00            $0.00


                                                                   Hours per
     Hourly Pay                                                     Week     Pay Rate  Weeks     OT Pay Rate      Wages
                                                        SHL                                 0.00                       $0.00
                                               Hourly Respite                               0.00                       $0.00
                                                Daily Respite                               0.00                       $0.00
                                                    Overtime                                                           $0.00
                               NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                         more than the weekly authorized units.

                                                                             Number of
     Other Compensation                                             Amount   Payments    Wages
                                                      Bonuses                               $0.00
                                                 Paid Holidays                              $0.00
                                                  Vacation Pay                              $0.00
                                                    Sick Leave                              $0.00
                                                 Other -Specify                             $0.00


10                                                                          Weeks        S.U.T.A.   Total Annual
      Employee Name                                Begin Date      End Date Employed       Rate       Wages      Annual Taxes    Annual Total
                                                                                  0.00                     $0.00         $0.00            $0.00


                                                                   Hours per
     Hourly Pay                                                     Week     Pay Rate  Weeks     OT Pay Rate      Wages
                                                        SHL                                 0.00                       $0.00
                                               Hourly Respite                               0.00                       $0.00
                                                Daily Respite                               0.00                       $0.00
                                                    Overtime                                                           $0.00
                               NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                         more than the weekly authorized units.

                                                                             Number of
     Other Compensation                                             Amount   Payments    Wages
                                                      Bonuses                               $0.00
                                                 Paid Holidays                              $0.00
                                                  Vacation Pay                              $0.00
                                                    Sick Leave                              $0.00
                                                 Other -Specify                             $0.00




                                                                                                                                                  Date and Time Created
                                                                                                                                                      8/31/2012 1:11 PM
Texas Department of                                                                                                                   HCS CDS Budget
Aging and Disability Services                                                                                                             August 2008




                                                      Home and Community Based Services
                                                                       Quarterly Report

                                      0                                                                                0
                                Consumer Name                                                                   Medicaid Number

                    Quarterly Report Coverage Period From:                                                To:
                                          Quarter Number:


                                              NOTE - All Budgeted Amounts on the Quarterly Report are Estimates


                                                                  Supported Home Living
                                                                   Auth Units              Billed Units           Auth Dollars    Billed Dollars
                                  Quarter 1                            0                                             $0.00             $0.00
                                  Quarter 2                            0                                             $0.00             $0.00
                                  Quarter 3                            0                                             $0.00             $0.00
                                  Quarter 4                            0                                             $0.00             $0.00
                                    Total                              0                        0                    $0.00            $0.00
                                  Remaining                            0                                             $0.00


                                                                       Hourly Respite
                                                                   Auth Units              Billed Units           Auth Dollars    Billed Dollars
                                  Quarter 1                            0                                             $0.00             $0.00
                                  Quarter 2                            0                                             $0.00             $0.00
                                  Quarter 3                            0                                             $0.00             $0.00
                                  Quarter 4                            0                                             $0.00             $0.00
                                    Total                              0                        0                    $0.00            $0.00
                                  Remaining                            0                                             $0.00

                                                                           Daily Respite
                                                                   Auth Units              Billed Units           Auth Dollars    Billed Dollars
                                  Quarter 1                            0                                             $0.00             $0.00
                                  Quarter 2                            0                                             $0.00             $0.00
                                  Quarter 3                            0                                             $0.00             $0.00
                                  Quarter 4                            0                                             $0.00             $0.00
                                    Total                              0                        0                    $0.00            $0.00
                                  Remaining                            0                                             $0.00


                                                                                Dental
                                                                   Auth Units              Billed Units           Auth Dollars    Billed Dollars
                                  Quarter 1                                                                          $0.00
                                  Quarter 2                                                                          $0.00
                                  Quarter 3                                                                          $0.00
                                  Quarter 4                                                                          $0.00
                                    Total                              0                        0                    $0.00            $0.00
                                  Remaining                            0                                             $0.00


                                                                        Adaptive Aids
                                                                   Auth Units              Billed Units           Auth Dollars    Billed Dollars
                                  Quarter 1                                                                          $0.00
                                  Quarter 2                                                                          $0.00
                                  Quarter 3                                                                          $0.00
                                  Quarter 4                                                                          $0.00
                                    Total                              0                        0                    $0.00            $0.00
                                  Remaining                            0                                             $0.00


                                                                Minor Home Modifications
                                                                   Auth Units              Billed Units           Auth Dollars    Billed Dollars
                                  Quarter 1                                                                          $0.00
                                  Quarter 2                                                                          $0.00
                                  Quarter 3                                                                          $0.00
                                  Quarter 4                                                                          $0.00
                                    Total                              0                        0                    $0.00            $0.00
                                  Remaining                            0                                             $0.00




                                                                                                                                  Date and Time Created
                                                                                                                                      8/31/2012 1:11 PM
Texas Department of                                                                                                                                                   HCS CDS Budget
Aging and Disability Services                                                                                                                                             August 2008




                                                             Home and Community Based Services
                                                                                    Quarterly Report

                                      0                                                                                                     0
                                Consumer Name                                                                                        Medicaid Number

                    Quarterly Report Coverage Period From:                                                              To:
                                          Quarter Number:


                                                  NOTE - All Budgeted Amounts on the Quarterly Report are Estimates


                                                                           Employer Support Services
                                                                               Auth Units                Billed Units                  Auth Dollars               Billed Dollars
                                    Quarter 1                                                                                             $0.00
                                    Quarter 2                                                                                             $0.00
                                    Quarter 3                                                                                             $0.00
                                    Quarter 4                                                                                             $0.00
                                     Total                                          0                          0                          $0.00                       $0.00
                                   Remaining                                        0                                                     $0.00


                                                                        Support Consultation Services
                                                                               Auth Units                Billed Units                  Auth Dollars               Billed Dollars
                                    Quarter 1                                      0                                                      $0.00                        $0.00
                                    Quarter 2                                      0                                                      $0.00                        $0.00
                                    Quarter 3                                      0                                                      $0.00                        $0.00
                                    Quarter 4                                      0                                                      $0.00                        $0.00
                                     Total                                          0                          0                          $0.00                       $0.00
                                   Remaining                                        0                                                     $0.00


                                                              Non-Taxable Employee Compensation Costs
                                                                               Auth Units                Billed Units                  Auth Dollars               Billed Dollars
                                    Quarter 1                                                                                             $0.00
                                    Quarter 2                                                                                             $0.00
                                    Quarter 3                                                                                             $0.00
                                    Quarter 4                                                                                             $0.00
                                     Total                                          0                          0                          $0.00                       $0.00
                                   Remaining                                        0                                                     $0.00


                                                                                 TOTAL BUDGET
                                                                                         Auth Dollars                                          Billed Dollars
                                    Quarter 1                                               $0.00                                                   $0.00
                                    Quarter 2                                               $0.00                                                   $0.00
                                    Quarter 3                                               $0.00                                                   $0.00
                                    Quarter 4                                               $0.00                                                   $0.00
                                      Total                                                 $0.00                                                     $0.00
                                                                                        TOTAL BUDGET REMAINING:                                       $0.00


                                          Dollars Remaining
                                                                                                                                                  $0.00
                          (negative indicates the consumer has overspent):
                                 Percent of Budgeted Dollars Spent
                      (negative amount indicates the consumer has overspent):
                                                                                                                                                  #DIV/0!
                                                          NOTE - The consumer must not develop a regular employee schedule
                                                           that contains fewer than or more than the weekly authorized units.


                                CERTIFICATION: By signature below I certify that the numbers entered into this quarterly report are accurate as reported to me.




                                    CDS Agency Representative Printed Name
                                                                                                                                       Phone Number (with Area Code)




                                      CDS Agency Representative Signature                                                     Date




                                                                                                                                                                  Date and Time Created
                                                                                                                                                                      8/31/2012 1:11 PM
Texas Department of                                                                       CLASS CDS Budget
Aging and Disability Services                                                                   August 2008




                                Home and Community Based Services
                                       Consumer Directed Services Budget

                                Taxable and Non-Taxable Employee Compensation

                         THIS PAGE IS NOT CONSIDERED PART OF CLIENT BUDGET



                                    TAXABLE EMPLOYEE COMPENSATION
   SALARIES/WAGES                                         MILEAGE (MAXIMUM IS 48.5¢ PER MILE)
   (Includes Employee-Paid Payroll Taxes:)                (Not Directly Related to Client Care)
        Regular Time                                         Communiting Costs & Assistance
        Overtime
        Bonus
        Paid Vacation Leave
        Paid Sick Leave
        Paid Other Leave (Jury Duty, Funeral, etc.)




                                  NON-TAXABLE EMPLOYEE COMPENSATION
   EMPLOYEE BENEFITS/INSURANCE                            MILEAGE (MAXIMUM IS 48.5¢ PER MILE)
     Insurance Premiums and Paid Claims,                  (Use of Employee's Personal Car Directly Related
         Including Health/Medical/Dental/Disability       Related to Client Care)
     Life Insurance Premiums                                 Client Appointments
     Employer-Paid Contributions to:                         Shopping
         Deferred Compensation Plans                         Escort
         Retirement & Pension Plans
         Child Day Care                                   WORKERS' COMPENSATION COSTS
         Accrued Leave                                      Premium Costs
                                                            Paid Claims
   PAYROLL TAXES (EMPLOYER-PAID)                            Other Premium/Claims for Employee
     FICA                                                   Work-Related Injury/Illness Coverage
     MEDICARE
     SUTA                                                 CONTRACTED SERVICE FEE
     FUTA                                                 (When Contracted With an Agency)
     Other as applicable                                     Back-Up PAS
                                                             In-Home Respite




                                                                                        Date and Time Created
                                                                                            8/31/2012 1:11 PM

								
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