Provider Costs Worksheet DHS by 4mZG9ne

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									                                                                               PROVIDER COSTS WORKSHEETS - Draft
                                                                                            Instructions {Page 1 of 22}
                                                                               Confidential Working Document: RIGL 38-2-2 (4)(B)

                            Organizations with TOTAL Revenue of less than $100,000 from all funding sources are Exempt from reporting financial data
                            If your organization has Total Revenue of Less Than $100,000, please submit this document with ONLY the Organization Profile Tab duly completed
                            indicating Total Revenue as being <$100,000 for the reporting period



                            Please use FISCAL YEAR 2006 DATA

I                          Organization Profile
                            Self Explanatory
                            If your organization has more than one FEIN, a separate Provider Costs document is to be submitted for each FEIN

                            Our preference is for the organization to complete this document using data from which Audited Financial Statements had been prepared. If your
                            organization does not prepare audited statements, please use the next most reliable source of data, as it relates to your organization, including, if
                            applicable, using Income Tax Basis Financial Statements in accordance with accounting standards
                            Line numbers loosely correspond to IRS Form 990 that is prepared by non-profit organizations. If your organization does not prepare the 990, please use
                            the Line Item descriptions to report per your General Ledger
                            You may have to combine or separate items from your accounting system to match line descriptions for Revenue and Expense in the Tabs

                            There are 3 specific Program Tabs, another Tab in which you should combine data for all other Programs, and a separate Tab for NON-Program revenue
                            & expense
                            Regarding Schedules II_a to II_c, please use only those Program tabs that relate to your organization.
                            Typically you are likely to use one or more of the specific Program tabs + Sch IIe {Other Programs} + Sch IIf {NON Program}. You will then need to use the
                            Summary tab to enter G/L and Indirect Expense, and the Reconciliation tab to connect data sources
    Schedules IIa to IIf




                            For example, if your organization has a Day program and some other program for which a distinct Tab does NOT appear in this workbook, please use Tab
                            IIb for the Day Program and Tab IIe Other Programs in which you will report the combined amounts of all remaining Program services. In this case, it is
                            expected that the sum of the two Tabs namely Day and OtherProgs will account for all Program revenue and Program expenses of the organization
                            Copays and Contracts should be reported in the Line of Business for that Revenue. DEA co-pay program $ should be reported in Col 1 (Medicaid)
                            If you know that a Copay or Contract is for the DAY Program, but you do not know if it relates to Medicaid, Medicare, etc, please report that Revenue in the
                            DAY Tab in {Col 8 Other} for Line 0225 or Line 0250 as applicable
                            SSI is to be reported in Column 5 for non-Medicaid. Identify as SSI in the Comment Column
                            In Col. 9 Please identify the UNIT of SERVICE such as Qtr Hour, Hour, Day, or Individual (applicable to the program reported in that Tab); If billing units
                            are different for other funding sources for that program, please report in terms of the units you use for the Medicaid program

IIa Sch A Program 1 Skilled HomeHealth                                    Data specific to the Home Health program.

IIb Sch A Program 2 Adult Day                                             Data specific to the Day program.

IIc Sch A Program 3 Assisted Living                                       Data specific to the Assisted Living program.

                                       IId Sch A Program 4                Please DISREGARD

                                                                          In the Other Programs Tab please combine ALL Other PROGRAM Revenue or PROGRAM Expense you did
IIe Sch A Program 5 Other Programs
                                                                          not report in specific Program Tabs
                                                          PROVIDER COSTS WORKSHEETS - Draft
                                                                      Instructions {Page 2 of 22}
                                                         Confidential Working Document: RIGL 38-2-2 (4)(B)



IIf Sch A NON-Program related                        ALL Other Revenue and the remaining expenses not reported in Program Tabs will be reported in this Tab.


II    Schedule B Summary of Sch II a to II f
       Generally, you can enter data in cells that are Not shaded or colored Yellow
       Columns 3 to 8 of this Summary, roll-up underlying data that you entered in program-specific worksheets such as Day and OtherProgs
       Columns 3 to 8 of the Summary worksheet do not require data entry
       Column 4 relating to Medicare, please ensure that at a Minimum, Revenue is to be reported
       Column 9: Lines up to 4450 have formulas that total the program tabs
       Column 10: Report data per your General Ledger & Financial Statements; If Net Worth is Negative, please explain in Comments Col 14
       Column 11 to 12: Self explanatory
       Column 13: Allowable Indirect Expenses: Difference between Total Program Expenses [Col 9] and the Allowed amount [Col 12]
       The worksheet is set up to allocate Indirect Expense [Col 13] using % of "category" Revenue to Total Revenue. If, in the program specific Tabs, you report
       certain costs that you allocate using another methodology, identify the methodology in the Comments column. Remaining Indirect Expenses that are not
       Unallowable and that you have not applied already to specific programs , are to be reported in Col 13

       Column 14: Comments (Please Identify the Col # to which the Comment applies); For example, use this Col to clarify an unallowable expense

       Illustration of Indirect Cost Allocation :
       If, for example, Interest Expense per the GL is $20,000, and $5,000 is Unallowable, a balance of $15,000 is to be distributed across programs.
       If $1,000 is directly attributed to Tab_Day/Col_Medicaid, $2,000 to Tab_OtherProgs/Col_Medicaid, 3,000 to Tab_Day/Col_Other, and 4,000 to
       Tab_OtherProgs/Col_Private, this would result in 1k+2k+3k+4k = 10k as Reported Interest Exp $ in Col. 9 of the Summary schedule. In this example, for
       Interest Exp $ that you attributed directly to specific programs, please record the applicable amount in the pertinent tab and in the Comments Col. of the
       tab please explain the allocation methodology.

       The Balance of Allowable less Reported, that is 15,000-10,000 = 5,000 is allocated as an Indirect Expense using a uniform methodology, based on the %
       of Revenue formula stated above.

       The allocation method you use for a particular Line Item should be the same across tabs. It's possible that you will use different allocation methods for
       different types of Line Items. We may require that a copy of the expense allocation prepared by you is provided with this worksheet.

       Line 4380 shows the the indirect allocated amounts from various Line items. For example, if the revenue distribution matched the distribution of $10k
       stated above in this example, you would expect to see the balance of $5k in amounts of 500, 1000, 1500 and 2000.

       In the Reconciliation Tab [III], itemize and explain differences between Total Reported Revenues or Expenses compared with the General Ledger


III   Sch C Reconciliation to IRS Form 990 and Financial Statements + Average Program Personnel Compensation
       Itemize reasons for difference between Total Reported Revenues and/or Expenses compared with the General Ledger amounts, within available lines.
       You may have to group items and combine $ amounts as needed
                                                   PROVIDER COSTS WORKSHEETS - Draft
                                                              I Org Profile

                                Federal Employer Identification Number (FEIN)

                                                                   Organization Name

                   Type: For Profit (P) or Non-Profit (N) (enter P or N accordingly)

                                                       Preparer's Name: (please print)

                                                                       Preparer's Title

                                                                      Preparer's Tel #

                                                                        Date Prepared

Financial Statements if Audited (enter "A"), if Reviewed ("R"), or if neither audited
                                                                 nor reviewed ("N")
           If your Financial Statements are prepared on the Income Tax Basis of
                                                           Accounting (enter "I")

                 Basis of Accounting: Accrual Basis (enter "A"), Cash Basis ("C")

                                       If Other Basis of accounting, please explain


              Fiscal Year Reported - Please indicate Period Ending MMDDYYYY


                                                Total Revenue for Reporting Period        $0

                                                               Accounting Firm Name

                                                             Accounting Firm Contact

                                                                Accounting Firm Tel #

                                          I hereby certify that the information submitted is complete, accurate and true.

                        Certification by CEO or CFO (NAME - please print)

                                                  Title (identify if CEO or CFO)

                Signature (or last 4 digits of SS# if submitted electronically)

                                                                       Date Certified

INDEX OF SCHEDULES                                                                        Comment
Typically you are likely to use one or more of the specific Program tabs + Sch IIe {Other Programs} + Sch IIf {NON Program}. You will then need to use the Summary tab to enter
                                                    G/L and Indirect Expense, and the Reconciliation tab to connect data sources
I   Organization Profile


                                                                                          Data specific to the Residential or Skilled Home Health program. DEA co-pay program $
IIa Sch A Program 1 Skilled HomeHealth
                                                                                          should be reported in Col 1 (Medicaid)
                                                                                          Data specific to the Day program. DEA co-pay program $ should be reported in Col 1
IIb Sch A Program 2 Adult Day
                                                                                          (Medicaid)
                                                                                          Data specific to the Assisted Living program. DEA co-pay program $ should be reported
IIc Sch A Program 3 Assisted Living
                                                                                          in Col 1 (Medicaid)
                                 IId Sch A Program 4                                      Please DISREGARD

                                                                                          In the Other Programs Tab please Combine ALL Other PROGRAM Revenue or
IIe Sch A Program 5 Other Programs
                                                                                          PROGRAM Expense you did not report in specific Program Tabs
                                                                                          Difference between Total Reported Revenues and/or Expenses compared with the General
                                                                                          Ledger amounts are to be explained in the Reconciliation tab [see III].
IIf Sch A NON Program related                                                             Revenue from All Other Sources and Non Program Expenses

                                                                                          Col 3 to 8 roll-up from the Sch II a to II f. Column 10 to 13 to be completed per the
II Schedule B SUMMARY of Program Tabs and All Other [Sch II a to II f]                    General Ledger for P&L and Balance Sheet data, and indirect expenses that you have not
                                                                                          allocated to specific programs

III Sch C Reconciliation to IRS Form 990 and/or Financial Statements +                    Reconciliation to IRS Form 990 if applicable and Financial Statements plus Reporting of
Average Program Personnel Compensation                                                    Average Compensation
PROVIDER COSTS WORKSHEETS                                                                                                        IIa SchA HomeHealth Prog                                                                                                                            Draft [Pg. 4 of 22]

     FEIN     0
     RES C1   RES C2                                                           RES C3                       RES C4                       RES C5                     RES C6                       RES C7                       RES C8                                     RES C9
                                                                                                                                                                                                                     SOURCE OF FUNDS: Other
                                                                          SOURCE OF FUNDS:             SOURCE OF FUNDS:         SOURCE OF FUNDS: Other        SOURCE OF FUNDS:          SOURCE OF FUNDS: Private                               Comments (Please Identify the Col # to which
     Line #   Description                                                                                                                                                                                             Rev & Exp [such as Other
                                                                              Medicaid                     Medicare              State Issued Non-Medicaid       City / Town                Funds e.g., Grants                                           the Comment applies)
                                                                                                                                                                                                                            Insurance]
     0010     Agency: Funding Source (eg DHS, MHRH etc)

     0015     Program (eg Home Health, Day, etc)                             Home Health                  Home Health                  Home Health                Home Health                  Home Health                  Home Health

     0020     Provider Type
                                                                                                                                                                                                                                                    Clarify Units Type
     0030     # of Units of Service (Clarify Units TYPE in Comments                        -                            -                             -                         -                            -                              -
              Column: Hrs, Days, etc)

              Total Units (Clarify Units TYPE in Comments Column:                                                                                                                                                                                   Clarify Units Type {same as above)
     0040
              Hrs, Days, etc)                                                              -                            -                             -                         -                            -                              -
     0050     % of Units

     0060     Staffing (Full Time Equiv: Payroll Hrs @ 1820 hrs/yr)

     0100     REV Grants, Gifts, etc.                                 $                        -   $                        -   $                         -   $                     -    $                       -   $                          -
     0200     REV Program Revenue                                                                                                                                                                                                               -
     0225     REV Copays
     0250     REV Contracts
     0300     REV Dues, Fees, Assessments
     0400     REV Interest
     0500     REV Investment Income
     0600     REV Rental income
     0800     REV Sale of Assets
     0900     REV Events, Activities
     1000     REV Sale of Inventory (net)
     1100     REV Other Revenue

     1200     REVENUE Total                                           $                        -   $                        -   $                         -   $                     -    $                       -   $                          -
                                                                                                                                                                                                                                                                                                -
              EXP Officers, Directors, Key Emp. Compensation
     2500                                                             $                        -   $                        -   $                         -   $                     -    $                       -   $                          -
              [This Program ONLY]

     2505     EXP PR Tax, Benefits & Wkr Comp Ln2500

              EXP Mgmt & Admin Sal. (not in Ln 2500) [This
     2550
              program ONLY]

     2555     EXP PR Tax, Benefits & Wkr Comp Ln 2550

              EXP Sal/Wages - Direct Care Program staff (not in
     2600
              above) [This program ONLY]
              EXP Sal/Wages - Rehab/Therapy Program staff
     2601
              (not in above) [This program ONLY]
              EXP Sal/Wages - Professional Oversight staff (not
     2602
              in above) [This program ONLY]

     2605     EXP PR Tax,Ben.,Wkr Comp [Ln 2600..2602]

              EXP Other Compensation (not in above) [This
     2700
              program ONLY]
              EXP Employee Benefits (not in above) [This
     2800
              program ONLY]
              EXP Payroll Taxes (not in above) [This program
     2900
              ONLY]
              EXP Workers Comp (not in above) [This program
     2910
              ONLY]




                                                                                                                                                                                                                                                                         IIa SchA HomeHealth Prog {Page 4 of 22}
PROVIDER COSTS WORKSHEETS                                                                                             IIa SchA HomeHealth Prog                                                                                                             Draft [Pg. 5 of 22]

     FEIN     0
     RES C1   RES C2                                                    RES C3                     RES C4                     RES C5                   RES C6                    RES C7                      RES C8                              RES C9
                                                                                                                                                                                                    SOURCE OF FUNDS: Other
                                                                   SOURCE OF FUNDS:           SOURCE OF FUNDS:       SOURCE OF FUNDS: Other       SOURCE OF FUNDS:       SOURCE OF FUNDS: Private                             Comments (Please Identify the Col # to which
     Line #   Description                                                                                                                                                                            Rev & Exp [such as Other
                                                                       Medicaid                   Medicare            State Issued Non-Medicaid      City / Town             Funds e.g., Grants                                         the Comment applies)
                                                                                                                                                                                                           Insurance]
     3000     EXP Fundraising & Events
     3100     EXP Accounting
     3200     EXP Legal
     3220     EXP Contract Personnel - Program
     3240     EXP Contract Personnel - Admin/Support
     3300     EXP Supplies
     3400     EXP Utilities: Tel., Elec., Heat, etc.
     3600     EXP Facilities Rent, Lease & Repairs
     3700     EXP Equipment Rent, Lease & Repairs
     3900     EXP Travel, Conferences
     4100     EXP Interest
     4200     EXP Depreciation
     4310     EXP Insurance: Property, Liability
     4320     EXP Advertising - Help Wanted
     4330     EXP Advertising: Promotional, PR, Lobbying
     4340     EXP Bad Debt
     4350     EXP Other (such as BCI) ______________
     4355     EXP Other ______________
     4360     EXP Other ______________
     4365     EXP Other ______________
     4370     EXP Other ______________

     4380     EXP Allocated Indirect Exp [Rev % of Ttl.Rev]

     4400     EXP Total                                        $                      -   $                      -   $                        -   $                  -    $                    -    $                        -
                                                                                                                                                                                                                                                                        -
     4450     NET of Revenue-Expense                           $                      -   $                      -   $                        -   $                  -    $                    -    $                        -
                                                                                                                                                                                                                                                                        -

     4500     Cash & Short-term Investments
     4550     Other Current Assets
     5900     Total Assets
     6000     Current Liabilities
     6600     Total Liabilities
     6650     Net Assets, Equity or Fund Balance
     6700     Fund Balance: Unrestricted
     6800     Fund Balance: Temporarily Restricted
     6900     Fund Balance: Permanently Restricted

                                                              Home Health




                                                                                                                                                                                                                                                 IIa SchA HomeHealth Prog {Page 5 of 22}
PROVIDER COSTS WORKSHEETS                                                                                                            IIb SchA Day Prog                                                                                                                             Draft [Pg. 6 of 22]

   FEIN     0
   DAY C1   DAY C2                                                           DAY C3                      DAY C4                      DAY C5                    DAY C6                      DAY C7                      DAY C8                                         DAY C9
                                                                                                                                                                                                              SOURCE OF FUNDS: Other
                                                                        SOURCE OF FUNDS:            SOURCE OF FUNDS:        SOURCE OF FUNDS: Other        SOURCE OF FUNDS:        SOURCE OF FUNDS: Private                                    Comments (Please Identify the Col # to which the
   Line #   Description                                                                                                                                                                                        Rev & Exp [such as Other
                                                                            Medicaid                    Medicare             State Issued Non-Medicaid       City / Town              Funds e.g., Grants                                                   Comment applies)
                                                                                                                                                                                                                     Insurance]
   0010     Agency: Funding Source (eg DHS, MHRH etc)

   0015     Program (eg Home Health, Day, etc)                              Adult Day                   Adult Day                   Adult Day                 Adult Day                   Adult Day                   Adult Day

   0020     Provider Type
                                                                                                                                                                                                                                            Clarify Units Type
   0030     # of Units of Service (Clarify Units TYPE in Comments                       -                           -                             -                       -                           -                             -
            Column: Hrs, Days, etc)

            Total Units (Clarify Units TYPE in Comments Column:                                                                                                                                                                             Clarify Units Type {same as above)
   0040
            Hrs, Days, etc)                                                             -                           -                             -                       -                           -                             -
   0050     % of Units

   0060     Staffing (Full Time Equiv: Payroll Hrs @ 1820 hrs/yr)

   0100     REV Grants, Gifts, etc.                                 $                       -   $                       -   $                         -   $                   -    $                      -
   0200     REV Program Revenue                                                                                         -                                                                                                               -
   0225     REV Copays
   0250     REV Contracts
   0300     REV Dues, Fees, Assessments
   0400     REV Interest                                                                                                                                                                                                                -
   0500     REV Investment Income
   0600     REV Rental income
   0800     REV Sale of Assets
   0900     REV Events, Activities                                                                                                                                                                        -
   1000     REV Sale of Inventory (net)
   1100     REV Other Revenue                                                                                                                                                 -                           -                             -

   1200     REVENUE Total                                           $                       -   $                       -   $                         -   $                   -    $                      -   $                         -
                                                                                                                                                                                                                                                                                                    -
            EXP Officers, Directors, Key Emp. Compensation
   2500                                                             $                       -   $                       -   $                         -   $                   -    $                      -   $                         -
            [This Program ONLY]

   2505     EXP PR Tax, Benefits & Wkr Comp Ln2500                                                                                                                                                                                      -

            EXP Mgmt & Admin Sal. (not in Ln 2500) [This
   2550
            program ONLY]

   2555     EXP PR Tax, Benefits & Wkr Comp Ln 2550

            EXP Sal/Wages - Direct Care Program staff (not in
   2600
            above) [This program ONLY]
            EXP Sal/Wages - Rehab/Therapy Program staff
   2601
            (not in above) [This program ONLY]
            EXP Sal/Wages - Professional Oversight staff (not
   2602
            in above) [This program ONLY]

   2605     EXP PR Tax,Ben.,Wkr Comp [Ln 2600..2602]

            EXP Other Compensation (not in above) [This
   2700                                                                                                                                                                                                                                 -
            program ONLY]
            EXP Employee Benefits (not in above) [This
   2800                                                                                                                                                                                                                                 -
            program ONLY]
            EXP Payroll Taxes (not in above) [This program
   2900                                                                                                                                                                                                                                 -
            ONLY]
            EXP Workers Comp (not in above) [This program
   2910
            ONLY]




                                                                                                                                                                                                                                                                                 IIb SchA Day Prog {Page 6 of 22}
PROVIDER COSTS WORKSHEETS                                                                                                   IIb SchA Day Prog                                                                                                               Draft [Pg. 7 of 22]

   FEIN     0
   DAY C1   DAY C2                                                      DAY C3                   DAY C4                     DAY C5                   DAY C6                     DAY C7                     DAY C8                                 DAY C9
                                                                                                                                                                                                  SOURCE OF FUNDS: Other
                                                                 SOURCE OF FUNDS:           SOURCE OF FUNDS:       SOURCE OF FUNDS: Other       SOURCE OF FUNDS:       SOURCE OF FUNDS: Private                               Comments (Please Identify the Col # to which the
   Line #   Description                                                                                                                                                                            Rev & Exp [such as Other
                                                                     Medicaid                   Medicare            State Issued Non-Medicaid      City / Town             Funds e.g., Grants                                              Comment applies)
                                                                                                                                                                                                         Insurance]
   3000     EXP Fundraising & Events                                                                                                                                                                                      -
   3100     EXP Accounting                                                                                                                                                                                                -
   3200     EXP Legal
   3220     EXP Contract Personnel - Program                                                                                                                                                                              -
   3240     EXP Contract Personnel - Admin/Support                                                                                                                                                                        -
   3300     EXP Supplies                                                                                                                                                                                                  -
   3400     EXP Utilities: Tel., Elec., Heat, etc.                                                                                                                                                                        -
   3600     EXP Facilities Rent, Lease & Repairs                                                                                                                                                                          -
   3700     EXP Equipment Rent, Lease & Repairs                                                                                                                                                                           -
   3900     EXP Travel, Conferences                                                                                                                                                                                       -
   4100     EXP Interest
   4200     EXP Depreciation                                                                                                                                                                                              -
   4310     EXP Insurance: Property, Liability                                                                                                                                                                            -
   4320     EXP Advertising - Help Wanted                                                                                                                                                                                 -
   4330     EXP Advertising: Promotional, PR, Lobbying                                                                                                                                                                    -
   4340     EXP Bad Debt                                                                                                                                                                                                  -
   4350     EXP Other (such as BCI) ______________                                                                                                                                                                        -
   4355     EXP Other ______________                                                                                                                                                                                      -
   4360     EXP Other ______________                                                                                                                                                                                      -
   4365     EXP Other ______________                                                                                                                                                                                      -
   4370     EXP Other ______________                                                                                                                                                                                      -

   4380     EXP Allocated Indirect Exp [Rev % of Ttl.Rev]

   4400     EXP Total                                        $                      -   $                      -   $                        -   $                  -    $                    -    $                       -
                                                                                                                                                                                                                                                                            -
   4450     NET of Revenue-Expense                           $                      -   $                      -   $                        -   $                  -    $                    -    $                       -
                                                                                                                                                                                                                                                                            -

   4500     Cash & Short-term Investments                                                                                                                                                                                                                                   -
   4550     Other Current Assets                                                                                                                                                                                                                                            -
   5900     Total Assets                                                                                                                                                                                                                                                    -
   6000     Current Liabilities                                                                                                                                                                                                                                             -
   6600     Total Liabilities                                                                                                                                                                                                                                               -
   6650     Net Assets, Equity or Fund Balance                                                                                                                                                                                                                              -
   6700     Fund Balance: Unrestricted                                                                                                                                                                                                                                           -
   6800     Fund Balance: Temporarily Restricted                                                                                                                                                                                                                            -
   6900     Fund Balance: Permanently Restricted                                                                                                                                                                                                                            -
                                                            Adult Day




                                                                                                                                                                                                                                                         IIb SchA Day Prog {Page 7 of 22}
PROVIDER COSTS WORKSHEETS                                                                                                                     IIc SchA AsstLvg Prog                                                                                                                                      Draft [Pg. 8 of 22]

       FEIN        0
       ASSTLV C1   ASSTLV C2                                               ASSTLV C3                        ASSTLV C4                        ASSTLV C5                       ASSTLV C6                      ASSTLV C7                       ASSTLV C8                       ASSTLV C9
                                                                                                                                                                                                                                            SOURCE OF FUNDS: Other
                                                                                SOURCE OF FUNDS:                 SOURCE OF FUNDS:            SOURCE OF FUNDS: Other           SOURCE OF FUNDS:              SOURCE OF FUNDS: Private                                        Comments (Please Identify the Col # to
       Line #      Description                                                                                                                                                                                                               Rev & Exp [such as Other
                                                                                    Medicaid                         Medicare                 State Issued Non-Medicaid          City / Town                    Funds e.g., Grants                                             which the Comment applies)
                                                                                                                                                                                                                                                   Insurance]
       0010        Agency: Funding Source (eg DHS, MHRH etc)

       0015        Program (eg Home Health, Day, etc)                             Assisted Living                  Assisted Living                 Assisted Living                Assisted Living                 Assisted Living                 Assisted Living

       0020        Provider Type
                                                                                                                                                                                                                                                                            Clarify Units Type
       0030        # of Units of Service (Clarify Units TYPE in Comments                            -                                -                               -                              -                               -                               -
                   Column: Hrs, Days, etc)

                   Total Units (Clarify Units TYPE in Comments Column:                                                                                                                                                                                                      Clarify Units Type {same as above)
       0040
                   Hrs, Days, etc)                                                                                                   -                               -                              -                               -                               -
       0050        % of Units

       0060        Staffing (Full Time Equiv: Payroll Hrs @ 1820 hrs/yr)
                                                                                                                                                                                                                                                        0
       0100        REV Grants, Gifts, etc.                                  $                           -    $                           -    $                          -    $                         -    $                          -    $                          -
       0200        REV Program Revenue                                                                                                                                                                                                                                  -
       0225        REV Copays
       0250        REV Contracts
       0300        REV Dues, Fees, Assessments
       0400        REV Interest
       0500        REV Investment Income
       0600        REV Rental income
       0800        REV Sale of Assets
       0900        REV Events, Activities                                                                                                                                                                                                                               -
       1000        REV Sale of Inventory (net)
       1100        REV Other Revenue                                                                                                                                                                                                                                    -

       1200        REVENUE Total                                            $                           -    $                           -    $                          -    $                         -    $                          -    $                          -
                                                                                                                                                                                                                                                                                                                  -
                   EXP Officers, Directors, Key Emp. Compensation
       2500                                                                 $                           -    $                           -    $                          -    $                         -    $                          -    $                          -
                   [This Program ONLY]

       2505        EXP PR Tax, Benefits & Wkr Comp Ln2500

                   EXP Mgmt & Admin Sal. (not in Ln 2500) [This
       2550                                                                                                                                                                                                                                                             -
                   program ONLY]

       2555        EXP PR Tax, Benefits & Wkr Comp Ln 2550                                                                                                                                                                                                              -

                   EXP Sal/Wages - Direct Care Program staff (not in
       2600                                                                                                                                                                                                                                                             -
                   above) [This program ONLY]
                   EXP Sal/Wages - Rehab/Therapy Program staff
       2601
                   (not in above) [This program ONLY]
                   EXP Sal/Wages - Professional Oversight staff (not
       2602                                                                                                                                                                                                                                                             -
                   in above) [This program ONLY]

       2605        EXP PR Tax,Ben.,Wkr Comp [Ln 2600..2602]                                                                                                                                                                                                             -

                   EXP Other Compensation (not in above) [This
       2700
                   program ONLY]
                   EXP Employee Benefits (not in above) [This
       2800                                                                                                                                                                                                                                                             -
                   program ONLY]
                   EXP Payroll Taxes (not in above) [This program
       2900
                   ONLY]
                   EXP Workers Comp (not in above) [This program
       2910
                   ONLY]




                                                                                                                                                                                                                                                                                                  IIc SchA AsstLvg Prog {Page 8 of 22}
PROVIDER COSTS WORKSHEETS                                                                                                   IIc SchA AsstLvg Prog                                                                                                               Draft [Pg. 9 of 22]

       FEIN        0
       ASSTLV C1   ASSTLV C2                                       ASSTLV C3                   ASSTLV C4                   ASSTLV C5                    ASSTLV C6               ASSTLV C7                  ASSTLV C8                   ASSTLV C9
                                                                                                                                                                                                           SOURCE OF FUNDS: Other
                                                                        SOURCE OF FUNDS:            SOURCE OF FUNDS:       SOURCE OF FUNDS: Other        SOURCE OF FUNDS:       SOURCE OF FUNDS: Private                               Comments (Please Identify the Col # to
       Line #      Description                                                                                                                                                                              Rev & Exp [such as Other
                                                                            Medicaid                    Medicare            State Issued Non-Medicaid       City / Town             Funds e.g., Grants                                    which the Comment applies)
                                                                                                                                                                                                                  Insurance]
       3000        EXP Fundraising & Events                                                                                                                                                                                        -
       3100        EXP Accounting                                                                                                                                                                                                  -
       3200        EXP Legal
       3220        EXP Contract Personnel - Program
       3240        EXP Contract Personnel - Admin/Support
       3300        EXP Supplies
       3400        EXP Utilities: Tel., Elec., Heat, etc.                                                                                                                                                                          -
       3600        EXP Facilities Rent, Lease & Repairs
       3700        EXP Equipment Rent, Lease & Repairs
       3900        EXP Travel, Conferences
       4100        EXP Interest
       4200        EXP Depreciation
       4310        EXP Insurance: Property, Liability
       4320        EXP Advertising - Help Wanted                                                                                                                                                                                   -
       4330        EXP Advertising: Promotional, PR, Lobbying
       4340        EXP Bad Debt
       4350        EXP Other (such as BCI) ______________
       4355        EXP Other ______________                                                                                                                                                                                        -
       4360        EXP Other ______________                                                                                                                                                                                        -
       4365        EXP Other ______________
       4370        EXP Other ______________

       4380        EXP Allocated Indirect Exp [Rev % of Ttl.Rev]

       4400        EXP Total                                        $                      -    $                      -    $                       -    $                  -    $                    -     $                      -
                                                                                                                                                                                                                                                                         -
       4450        NET of Revenue-Expense                           $                      -    $                      -    $                       -    $                  -    $                    -     $                      -
                                                                                                                                                                                                                                                                         -

       4500        Cash & Short-term Investments
       4550        Other Current Assets
       5900        Total Assets
       6000        Current Liabilities
       6600        Total Liabilities
       6650        Net Assets, Equity or Fund Balance
       6700        Fund Balance: Unrestricted
       6800        Fund Balance: Temporarily Restricted
       6900        Fund Balance: Permanently Restricted

                                                                   Assisted Living




                                                                                                                                                                                                                                                         IIc SchA AsstLvg Prog {Page 9 of 22}
PROVIDER COSTS WORKSHEETS                                                                                                            IIe SchA OtherProgs                                                                                                                     Draft [Pg. 10 of 22]

       FEIN      0
       OTHPROG C1OTHPROG C2                                                     OTHPROG C3                  OTHPROG C4                  OTHPROG C5                 OTHPROG C6                 OTHPROG C7                  OTHPROG C8                             OTHPROG C9
                                                                                                                                                                                                                    SOURCE OF FUNDS: Other
                                                                             SOURCE OF FUNDS:            SOURCE OF FUNDS:        SOURCE OF FUNDS: Other        SOURCE OF FUNDS:         SOURCE OF FUNDS: Private                                  Comments (Please Identify the Col # to
       Line #    Description                                                                                                                                                                                         Rev & Exp [such as Other
                                                                                 Medicaid                    Medicare             State Issued Non-Medicaid       City / Town               Funds e.g., Grants                                       which the Comment applies)
                                                                                                                                                                                                                           Insurance]
       0010      Agency: Funding Source (eg DHS, MHRH etc)

       0015      Program (eg Home Health, Day, etc)                                     OTHER [Pls. Identify those programs not reported in a specific tab_______________________________________________________________}

       0020      Provider Type
                                                                                                                                                                                                                                                  Clarify Units Type
       0030      # of Units of Service (Clarify Units TYPE in Comments                       -                           -                             -                        -                           -                             -
                 Column: Hrs, Days, etc)

                 Total Units (Clarify Units TYPE in Comments Column:                                                                                                                                                                              Clarify Units Type {same as above)
       0040
                 Hrs, Days, etc)                                                             -                           -                             -                        -                           -                             -
       0050      % of Units

       0060      Staffing (Full Time Equiv: Payroll Hrs @ 1820 hrs/yr)

       0100      REV Grants, Gifts, etc.                                 $                       -   $                       -   $                         -   $                    -    $                      -   $                         -
       0200      REV Program Revenue                                                                                                                                                                                                          -
       0225      REV Copays
       0250      REV Contracts
       0300      REV Dues, Fees, Assessments
       0400      REV Interest
       0500      REV Investment Income
       0600      REV Rental income
       0800      REV Sale of Assets
       0900      REV Events, Activities
       1000      REV Sale of Inventory (net)
       1100      REV Other Revenue

       1200      REVENUE Total                                           $                       -   $                       -   $                         -   $                    -    $                      -   $                         -
                                                                                                                                                                                                                                                   $                                    -
                 EXP Officers, Directors, Key Emp. Compensation
       2500                                                              $                       -   $                       -   $                         -   $                    -    $                      -   $                         -
                 [This Program ONLY]

       2505      EXP PR Tax, Benefits & Wkr Comp Ln2500                                                                      -                                                                                                                -

                 EXP Mgmt & Admin Sal. (not in Ln 2500) [This
       2550
                 program ONLY]

       2555      EXP PR Tax, Benefits & Wkr Comp Ln 2550

                 EXP Sal/Wages - Direct Care Program staff (not in
       2600
                 above) [This program ONLY]
                 EXP Sal/Wages - Rehab/Therapy Program staff
       2601
                 (not in above) [This program ONLY]
                 EXP Sal/Wages - Professional Oversight staff (not
       2602
                 in above) [This program ONLY]

       2605      EXP PR Tax,Ben.,Wkr Comp [Ln 2600..2602]

                 EXP Other Compensation (not in above) [This
       2700
                 program ONLY]
                 EXP Employee Benefits (not in above) [This
       2800
                 program ONLY]
                 EXP Payroll Taxes (not in above) [This program
       2900                                                                                                                                                                                                                                   -
                 ONLY]
                 EXP Workers Comp (not in above) [This program
       2910                                                                                                                                                                                                                                   -
                 ONLY]




                                                                                                                                                                                                                                                                        IIe SchA OtherProgs {Page 10 of 22}
PROVIDER COSTS WORKSHEETS                                                                                                    IIe SchA OtherProgs                                                                                                             Draft [Pg. 11 of 22]

       FEIN      0
       OTHPROG C1OTHPROG C2                                              OTHPROG C3                 OTHPROG C4                  OTHPROG C5                OTHPROG C6               OTHPROG C7                   OTHPROG C8                        OTHPROG C9
                                                                                                                                                                                                          SOURCE OF FUNDS: Other
                                                                      SOURCE OF FUNDS:           SOURCE OF FUNDS:        SOURCE OF FUNDS: Other       SOURCE OF FUNDS:       SOURCE OF FUNDS: Private                                 Comments (Please Identify the Col # to
       Line #    Description                                                                                                                                                                               Rev & Exp [such as Other
                                                                          Medicaid                   Medicare             State Issued Non-Medicaid      City / Town             Funds e.g., Grants                                      which the Comment applies)
                                                                                                                                                                                                                 Insurance]
       3000      EXP Fundraising & Events
       3100      EXP Accounting
       3200      EXP Legal
       3220      EXP Contract Personnel - Program
       3240      EXP Contract Personnel - Admin/Support                                                                                                                                                                           -
       3300      EXP Supplies                                                                                                                                                                                                     -
       3400      EXP Utilities: Tel., Elec., Heat, etc.                                                                                                                                                                           -
       3600      EXP Facilities Rent, Lease & Repairs                                                                                                                                                                             -
       3700      EXP Equipment Rent, Lease & Repairs                                                                                                                                                                              -
       3900      EXP Travel, Conferences                                                                                                                                                                                          -
       4100      EXP Interest                                                                                                                                                                                                     -
       4200      EXP Depreciation                                                                                                                                                                                                 -
       4310      EXP Insurance: Property, Liability                                                                                                                                                                               -
       4320      EXP Advertising - Help Wanted                                                                                                                                                                                    -
       4330      EXP Advertising: Promotional, PR, Lobbying                                                                                                                                                                       -
       4340      EXP Bad Debt                                                                                                                                                                                                     -
       4350      EXP Other (such as BCI) ______________                                                                                                                                                                           -
       4355      EXP Other ______________
       4360      EXP Other ______________
       4365      EXP Other ______________
       4370      EXP Other ______________

       4380      EXP Allocated Indirect Exp [Rev % of Ttl.Rev]

       4400      EXP Total                                        $                      -   $                       -   $                        -   $                  -    $                       -   $                       -
                                                                                                                                                                                                                                      $                                 -
       4450      NET of Revenue-Expense                           $                      -   $                       -   $                        -   $                  -    $                       -   $                       -
                                                                                                                                                                                                                                      $                                 -

       4500      Cash & Short-term Investments
       4550      Other Current Assets
       5900      Total Assets
       6000      Current Liabilities
       6600      Total Liabilities
       6650      Net Assets, Equity or Fund Balance
       6700      Fund Balance: Unrestricted
       6800      Fund Balance: Temporarily Restricted
       6900      Fund Balance: Permanently Restricted

                                                                 OTHER [Pls. Identify those programs not reported in a specific tab_______________________________________________________________}




                                                                                                                                                                                                                                                        IIe SchA OtherProgs {Page 11 of 22}
PROVIDER COSTS WORKSHEETS                                                                                           IIf SchA NONProg AllOther                                                                                                             Draft [Pg. 12 of 22]

                            FEIN      0
                            NONPROG C1NONPROG C2                                                                     NONPROG C8                                                              NONPROG C9

                                                                                             SOURCE OF FUNDS: ALL Other Rev & Indirect Exp, NOT included       Comments (Please Identify the Col # to which the Comment applies; Also see
                            Line #   Description
                                                                                                                in Program Tabs                                                  comment below re. the Summary Tab)

                            0010     Agency: Funding Source

                            0015     NON Program                                             ALL OTHER {$ NOT reported in any Program Tab}

                            0020     Provider Type

                            0030     # of Units of Service

                            0040     Total Units
                            0050     % of Units

                            0060     Staffing (Full Time Equiv: Payroll Hrs @ 1820 hrs/yr)

                            0100     REV Grants, Gifts, etc.                                  $                                                        -
                            0200     REV Program Revenue                                                                                               -
                            0225     REV Copays                                                                                                        -
                            0250     REV Contracts
                            0300     REV Dues, Fees, Assessments
                            0400     REV Interest
                            0500     REV Investment Income
                            0600     REV Rental income
                            0800     REV Sale of Assets
                            0900     REV Events, Activities
                            1000     REV Sale of Inventory (net)
                            1100     REV Other Revenue
                            1200     REVENUE Total                                            $                                                        -   $                                                                                -

                            2500     EXP Officers, Directors, Key Emp. Compensation

                            2505     EXP PR Tax, Benefits & Wkr Comp Ln2500

                            2550     EXP Mgmt & Admin Sal. (not in Ln 2500)

                            2555     EXP PR Tax, Benefits & Wkr Comp Ln 2550

                                     EXP Sal/Wages - Direct Care Program staff (not in
                            2600
                                     above) [This program ONLY]
                                     EXP Sal/Wages - Rehab/Therapy Program staff
                            2601
                                     (not in above) [This program ONLY]
                                     EXP Sal/Wages - Professional Oversight staff (not
                            2602
                                     in above) [This program ONLY]
                            2605     EXP PR Tax,Ben.,Wkr Comp [Ln 2600..2602]

                            2700     EXP Other Compensation (not in above)

                            2800     EXP Employee Benefits (not in above)

                            2900     EXP Payroll Taxes (not in above)

                            2910     EXP Workers Comp (not in above)




                                                                                                                                                                                                                                                IIf SchA NONProg AllOther {Page 12 of 22}
PROVIDER COSTS WORKSHEETS                                                                                  IIf SchA NONProg AllOther                                                                                                              Draft [Pg. 13 of 22]

                            FEIN      0
                            NONPROG C1NONPROG C2                                                            NONPROG C8                                                               NONPROG C9

                                                                                     SOURCE OF FUNDS: ALL Other Rev & Indirect Exp, NOT included       Comments (Please Identify the Col # to which the Comment applies; Also see
                            Line #   Description
                                                                                                        in Program Tabs                                                  comment below re. the Summary Tab)

                            3000     EXP Fundraising & Events
                            3100     EXP Accounting
                            3200     EXP Legal
                            3220     EXP Contract Personnel - Program
                            3240     EXP Contract Personnel - Admin/Support
                            3300     EXP Supplies
                            3400     EXP Utilities: Tel., Elec., Heat, etc.
                            3600     EXP Facilities Rent, Lease & Repairs
                            3700     EXP Equipment Rent, Lease & Repairs
                            3900     EXP Travel, Conferences
                            4100     EXP Interest
                            4200     EXP Depreciation
                            4310     EXP Insurance: Property, Liability
                            4320     EXP Advertising - Help Wanted
                            4330     EXP Advertising: Promotional, PR, Lobbying
                            4340     EXP Bad Debt
                            4350     EXP Other (such as BCI) ______________
                            4355     EXP Other __________
                            4360     EXP Other __________
                            4365     EXP Other __________
                            4370     EXP Other __________

                            4380     EXP Allocated Indirect Exp [Rev % of Ttl.Rev]

                            4400     EXPENSES Total                                  $                                                         -   $                                                                                -
                            4450     NET of Revenue-Expense                          $                                                         -   $                                                                                -

                            4500     Cash & Short-term Investments
                            4550     Other Current Assets
                            5900     Total Assets
                                                                                                                                                   Please check the Summary Tab to verify that you have reported
                            6000     Current Liabilities                                                                                           Expenses & Balance Sheet data per the General Ledger, and allowable
                                                                                                                                                   Indirect Expenses in the applicable columns [Summary Tab Columns
                            6600     Total Liabilities
                                                                                                                                                   10 to 13]. Expenses reported in this Tab would probably match data
                            6650     Net Assets, Equity or Fund Balance                                                                            you report in Col 13 of the Summary Tab except for Unallowable items
                                                                                                                                                   that would be shown on the Summary Tab in Col 11
                            6700     Fund Balance: Unrestricted
                            6800     Fund Balance: Temporarily Restricted
                            6900     Fund Balance: Permanently Restricted




                                                                                                                                                                                                                                        IIf SchA NONProg AllOther {Page 13 of 22}
PROVIDER COSTS WORKSHEETS                                                                             II Sch B Summary PROG and OTHER                                                                                         Draft [Pg. 14 of 22]

       FEIN     0                                                         Program related Expense and all Revenue, appear in this Summary sheet from various Tabs. (Also see Col 10-13)
       COL 1    COL 2                                                               COL 3                       COL 4                       COL 5                   COL 6                      COL 7                       COL 8
                                                                                                                                                                                                                    SOURCE OF FUNDS:
                                                                               SOURCE OF FUNDS:            SOURCE OF FUNDS:       SOURCE OF FUNDS: Other       SOURCE OF FUNDS:       SOURCE OF FUNDS: Private
       Line #   Description                                                                                                                                                                                       Revenue (All) & Prog Exp
                                                                                   Medicaid                    Medicare            State Issued Non-Medicaid      City / Town             Funds e.g., Grants
                                                                                                                                                                                                                 [Including Other Insurance]
       0010     Agency: Funding Source
       0015     Program (eg Day, Asst.Lvg, HmHlth)
       0020     Provider Type
       0030     # of Units of Service
       0040     Total Units
       0050     % of Units
       0060     Staffing (Full Time Equivalents @ 1820 hrs/yr)                        0                           0                           0                       0                          0                            0
       0100     REV Grants, Gifts, etc.                                    $                      -    $                      -   $                        -   $                  -    $                    -    $                         -
       0200     REV Program Revenue                                                               -                           -                            -                      -                         -                              -
       0225     REV Copays                                                                        -                           -                            -                      -                         -                              -
       0250     REV Contracts                                                                     -                           -                            -                      -                         -                              -
       0300     REV Dues, Fees, Assessments                                                       -                           -                            -                      -                         -                              -
       0400     REV Interest                                                                      -                           -                            -                      -                         -                              -
       0500     REV Investment Income                                                             -                           -                            -                      -                         -                              -
       0600     REV Rental income                                                                 -                           -                            -                      -                         -                              -
       0800     REV Sale of Assets                                                                -                           -                            -                      -                         -                              -
       0900     REV Events, Activities                                                            -                           -                            -                      -                         -                              -
       1000     REV Sale of Inventory (net)                                                       -                           -                            -                      -                         -                              -
       1100     REV Other Revenue                                                                 -                           -                            -                      -                         -                              -
       1200     REVENUE Total                                              $                      -    $                      -   $                        -   $                  -    $                    -    $                         -

       2500     EXP Officers, Directors, Key Emp. Compensation             $                      -    $                      -   $                        -   $                  -    $                    -    $                         -

       2505     EXP Ln 2500 PR Tax, Benefits & Wkr Comp                                           -                           -                            -                      -                         -                              -

       2550     EXP Mgmt & Admin Sal/Wages (not in Ln 2500)                                       -                           -                            -                      -                         -                              -

       2555     EXP Ln 2550 PR Tax, Benefits & Wkr Comp                                           -                           -                            -                      -                         -                              -
                EXP Sal/Wages - Direct Care Program staff (not reported
       2600                                                                                       -                           -                            -                      -                         -                              -
                above)
                EXP Sal/Wages - Rehab/Therapy Program staff (not in
       2601                                                                                       -                           -                            -                      -                         -                              -
                above)
                EXP Sal/Wages - Professional Oversight staff (not
       2602                                                                                       -                           -                            -                      -                         -                              -
                reported above)

       2605     EXP Ln 2600 & 2602 Payroll Tax, Benefits & Wkr Comp                               -                           -                            -                      -                         -                              -

       2700     EXP Other Compensation (not in above)                                             -                           -                            -                      -                         -                              -
       2800     EXP Employee Benefits (not in above)                                              -                           -                            -                      -                         -                              -
       2900     EXP Payroll Taxes (not in above)                                                  -                           -                            -                      -                         -                              -
       2910     EXP Workers Comp (not in above)                                                   -                           -                            -                      -                         -                              -




                                                                                                                                                                                                           II Sch B Summary PROG and OTHER {Page 14 of 22}
PROVIDER COSTS WORKSHEETS                                                                  II Sch B Summary PROG and OTHER                                                                                      Draft [Pg. 15 of 22]

       FEIN     0                                               Program related Expense and all Revenue, appear in this Summary sheet from various Tabs. (Also see Col 10-13)
       COL 1    COL 2                                                    COL 3                     COL 4                      COL 5                   COL 6                      COL 7                       COL 8
                                                                                                                                                                                                      SOURCE OF FUNDS:
                                                                   SOURCE OF FUNDS:          SOURCE OF FUNDS:       SOURCE OF FUNDS: Other       SOURCE OF FUNDS:       SOURCE OF FUNDS: Private
       Line #   Description                                                                                                                                                                         Revenue (All) & Prog Exp
                                                                       Medicaid                  Medicare            State Issued Non-Medicaid      City / Town             Funds e.g., Grants
                                                                                                                                                                                                   [Including Other Insurance]
       3000     EXP Fundraising & Events                                               -                        -                            -                      -                         -                              -
       3100     EXP Accounting                                                         -                        -                            -                      -                         -                              -
       3200     EXP Legal                                                              -                        -                            -                      -                         -                              -
       3220     EXP Contract Personnel - Program                                       -                        -                            -                      -                         -                              -
       3240     EXP Contract Personnel - Admin/Support                                 -                        -                            -                      -                         -                              -
       3300     EXP Supplies                                                           -                        -                            -                      -                         -                              -
       3400     EXP Utilities: Tel., Elec., Heat, etc.                                 -                        -                            -                      -                         -                              -
       3600     EXP Facilities Rent, Lease & Repairs                                   -                        -                            -                      -                         -                              -
       3700     EXP Equipment Rent, Lease & Repairs                                    -                        -                            -                      -                         -                              -
       3900     EXP Travel, Conferences                                                -                        -                            -                      -                         -                              -
       4100     EXP Interest                                                           -                        -                            -                      -                         -                              -
       4200     EXP Depreciation                                                       -                        -                            -                      -                         -                              -
       4310     EXP Insurance: Property, Liability                                     -                        -                            -                      -                         -                              -
       4320     EXP Advertising - Help Wanted                                          -                        -                            -                      -                         -                              -
       4330     EXP Advertising: Promotional, PR, Lobbying                             -                        -                            -                      -                         -                              -
       4340     EXP Bad Debt                                                           -                        -                            -                      -                         -                              -
       4350     EXP Other (such as BCI) ______________                                 -                        -                            -                      -                         -                              -
       4355     EXP Other ______________                                               -                        -                            -                      -                         -                              -
       4360     EXP Other ______________                                               -                        -                            -                      -                         -                              -
       4365     EXP Other ______________                                               -                        -                            -                      -                         -                              -
       4370     EXP Other ______________                                               -                        -                            -                      -                         -                              -

       4380     EXP Allocated Indirect Exp [Rev % of Ttl.Rev]           #VALUE!                  #VALUE!                    #VALUE!                  #VALUE!                   #VALUE!                     #VALUE!

       4400     EXPENSES Total                                         #VALUE!                   #VALUE!                    #VALUE!                  #VALUE!                   #VALUE!                     #VALUE!
       4450     NET of Revenue-Expense                                 #VALUE!                   #VALUE!                    #VALUE!                  #VALUE!                   #VALUE!                     #VALUE!

       4500     Cash & Short-term Investments
       4550     Other Current Assets
       5900     Total Assets
       6000     Current Liabilities
       6600     Total Liabilities
       6650     Net Assets, Equity or Fund Balance
       6700     Fund Balance: Unrestricted
       6800     Fund Balance: Temporarily Restricted
       6900     Fund Balance: Permanently Restricted

       7000     Operating Profit or Loss [$]



                                                                                                                                                                                             II Sch B Summary PROG and OTHER {Page 15 of 22}
PROVIDER COSTS WORKSHEETS                             II Sch B Summary PROG and OTHER                                                                                    Draft [Pg. 16 of 22]

       FEIN     0             Program related Expense and all Revenue, appear in this Summary sheet from various Tabs. (Also see Col 10-13)
       COL 1    COL 2                  COL 3                     COL 4                     COL 5                   COL 6                  COL 7                       COL 8
                                                                                                                                                               SOURCE OF FUNDS:
                                 SOURCE OF FUNDS:         SOURCE OF FUNDS:       SOURCE OF FUNDS: Other       SOURCE OF FUNDS:   SOURCE OF FUNDS: Private
       Line #   Description                                                                                                                                  Revenue (All) & Prog Exp
                                     Medicaid                 Medicare            State Issued Non-Medicaid      City / Town         Funds e.g., Grants
                                                                                                                                                            [Including Other Insurance]




                                                                                                                                                      II Sch B Summary PROG and OTHER {Page 16 of 22}
PROVIDER COSTS WORKSHEETS                                                                             II Sch B Summary PROG and OTHER                                                                                                   Draft [Pg. 17 of 22]

     FEIN     0                                                         Col 10 to 13: Expenses & Balance Sheet data per the General Ledger & allowable Indirect Expenses per Medicaid guidelines.
     COL 1    COL 2                                                           COL 9              COL 10                COL 11                COL 12                 COL 13                                         COL 14
                                                                          Reported [All                                                Allowable Expenses
                                                                                                                     Unallowable                          Indirect Exps to Allocate
     Line #   Description                                               Revenue & Program   Per General Ledger                              [G/L less                                 Comments (Please Identify the Col # to which the Comment applies)
                                                                                                                      Expenses                             [Allowable - Reported]
                                                                              Exp]                                                        Unallowable]
     0010     Agency: Funding Source
     0015     Program (eg Day, Asst.Lvg, HmHlth)
     0020     Provider Type
     0030     # of Units of Service
     0040     Total Units
     0050     % of Units
     0060     Staffing (Full Time Equivalents @ 1820 hrs/yr)                    0
     0100     REV Grants, Gifts, etc.                                    $             -    $                -
     0200     REV Program Revenue                                                       -   $                -
     0225     REV Copays                                                                -   $                -
     0250     REV Contracts                                                             -   $                -
     0300     REV Dues, Fees, Assessments                                               -   $                -
     0400     REV Interest                                                              -   $                -
     0500     REV Investment Income                                                     -   $                -
     0600     REV Rental income                                                         -   $                -
     0800     REV Sale of Assets                                                        -   $                -
     0900     REV Events, Activities                                                    -   $                -
     1000     REV Sale of Inventory (net)                                               -   $                -
     1100     REV Other Revenue                                                         -   $                -
     1200     REVENUE Total                                              $             -    $                -

     2500     EXP Officers, Directors, Key Emp. Compensation             $             -    $                -   $                 -    $               -

     2505     EXP Ln 2500 PR Tax, Benefits & Wkr Comp                                   -   $                -                                          -

     2550     EXP Mgmt & Admin Sal/Wages (not in Ln 2500)                               -   $                -                                          -

     2555     EXP Ln 2550 PR Tax, Benefits & Wkr Comp                                   -   $                -                                          -
              EXP Sal/Wages - Direct Care Program staff (not reported
     2600                                                                               -   $                -                                          -
              above)
              EXP Sal/Wages - Rehab/Therapy Program staff (not in
     2601                                                                               -   $                -                                          -
              above)
              EXP Sal/Wages - Professional Oversight staff (not
     2602                                                                               -   $                -                                          -
              reported above)

     2605     EXP Ln 2600 & 2602 Payroll Tax, Benefits & Wkr Comp                       -   $                -                                          -

     2700     EXP Other Compensation (not in above)                                     -   $                -                                          -
     2800     EXP Employee Benefits (not in above)                                      -   $                -                                          -
     2900     EXP Payroll Taxes (not in above)                                          -   $                -                                          -
     2910     EXP Workers Comp (not in above)                                           -   $                -                                          -




                                                                                                                                                                                                                     II Sch B Summary PROG and OTHER {Page 17 of 22}
PROVIDER COSTS WORKSHEETS                                                                   II Sch B Summary PROG and OTHER                                                                                                                 Draft [Pg. 18 of 22]

     FEIN     0                                               Col 10 to 13: Expenses & Balance Sheet data per the General Ledger & allowable Indirect Expenses per Medicaid guidelines.
     COL 1    COL 2                                                 COL 9              COL 10                        COL 11                      COL 12                 COL 13                                         COL 14
                                                                Reported [All                                                              Allowable Expenses
                                                                                                              Unallowable                                     Indirect Exps to Allocate
     Line #   Description                                     Revenue & Program   Per General Ledger                                            [G/L less                                 Comments (Please Identify the Col # to which the Comment applies)
                                                                                                               Expenses                                        [Allowable - Reported]
                                                                    Exp]                                                                      Unallowable]
     0010
     3000     Agency: Funding Source
              EXP Fundraising & Events                                        -   $                -                                                        -
     3100     EXP Accounting                                                  -   $                -                                                        -
     3200     EXP Legal                                                       -   $                -                                                        -
     3220     EXP Contract Personnel - Program                                -   $                -                                                        -
     3240     EXP Contract Personnel - Admin/Support                          -   $                -                                                        -
     3300     EXP Supplies                                                    -   $                -                                                        -
     3400     EXP Utilities: Tel., Elec., Heat, etc.                          -   $                -                                                        -
     3600     EXP Facilities Rent, Lease & Repairs                            -   $                -                                                        -
     3700     EXP Equipment Rent, Lease & Repairs                             -   $                -                                                        -
     3900     EXP Travel, Conferences                                         -   $                -                                                        -
     4100     EXP Interest                                                    -   $                -                                                        -
     4200     EXP Depreciation                                                -   $                -                                                        -
     4310     EXP Insurance: Property, Liability                              -   $                -                                                        -
     4320     EXP Advertising - Help Wanted                                   -   $                -                                                        -
     4330     EXP Advertising: Promotional, PR, Lobbying                      -   $                -                                                        -
     4340     EXP Bad Debt                                                    -   $                -                                                        -
     4350     EXP Other (such as BCI) ______________                          -   $                -                                                        -
     4355     EXP Other ______________                                        -   $                -                                                        -
     4360     EXP Other ______________                                        -   $                -                                                        -
     4365     EXP Other ______________                                        -   $                -                                                        -
     4370     EXP Other ______________                                        -   $                -                                                        -

     4380     EXP Allocated Indirect Exp [Rev % of Ttl.Rev]        #VALUE!

     4400     EXPENSES Total                                      #VALUE!         $                -    $                              -    $               -   $                     -
     4450     NET of Revenue-Expense                              #VALUE!         $                -                                                                                  -
                                                                                                       Please complete the Column on




     4500     Cash & Short-term Investments                                       $                -
                                                                                                       the left per General Ledger &




     4550     Other Current Assets                                                $                -
                                                                                                            Financial Statements




     5900     Total Assets                                                        $                -
     6000     Current Liabilities                                                 $                -
     6600     Total Liabilities                                                   $                -
     6650     Net Assets, Equity or Fund Balance                                  $                -
     6700     Fund Balance: Unrestricted                                          $                -
     6800     Fund Balance: Temporarily Restricted                                $                -
     6900     Fund Balance: Permanently Restricted                                $                -

     7000     Operating Profit or Loss [$]                                        $                -



                                                                                                                                                                                                                         II Sch B Summary PROG and OTHER {Page 18 of 22}
PROVIDER COSTS WORKSHEETS                                            II Sch B Summary PROG and OTHER                                                                                           Draft [Pg. 19 of 22]

     FEIN     0                        Col 10 to 13: Expenses & Balance Sheet data per the General Ledger & allowable Indirect Expenses per Medicaid guidelines.
     COL 1    COL 2                          COL 9              COL 10            COL 11            COL 12                 COL 13                                         COL 14
                                         Reported [All                                        Allowable Expenses
                                                                                Unallowable                      Indirect Exps to Allocate
     Line #   Description              Revenue & Program   Per General Ledger                      [G/L less                                 Comments (Please Identify the Col # to which the Comment applies)
                                                                                 Expenses                         [Allowable - Reported]
                                             Exp]                                                Unallowable]
     0010     Agency: Funding Source




                                                                                                                                                                            II Sch B Summary PROG and OTHER {Page 19 of 22}
PROVIDER COSTS WORKSHEETS                                      III Sch C Recon990_ FS_ProgSW                                                                                   Draft




                                                                                                                             FEIN 0

                                          Please accommodate reconciling explanations and $ in the 6 lines provided for each section
                                                                         Do NOT add rows or columns
                                       If your organization does not prepare IRS Form 990, disregard that section of the reconciliation
                                If possible, in your explanation, please Cross-reference Line Numbers from Col 1 of the underlying schedules

              Revenue Reconciled To IRS Form 990, if applicable

                                                                       Total Reported REVENUE (from II Schedule B Summary ) $                            -

              Rev Item 1 (Please describe) - If you do not prepare the IRS Form 990, describe as NA                                  $                   -
              Rev Item 2                                                                                                                                 -
              Rev Item 3                                                                                                                                 -
              Rev Item 4                                                                                                                                 -
              Rev Item 5                                                                                                                                 -
              Rev Item 6                                                                                                                                 -
                                                                      REVENUE reconciled to $ reported on IRS Form 990, if applcable $                   -

              Revenue (per IRS Form 990, if applicable) Reconciled To Financial Statements

              Rev Item I                                                                                                             $                   -
              Rev Item II                                                                                                                                -
              Rev Item III                                                                                                                               -
              Rev Item IV                                                                                                                                -
              Rev Item V                                                                                                                                 -
              Rev Item VI                                                                                                                                -
                                                                                    Total Reconciled Revenue per Financial Statements $                  -

                                 REVENUE per Financial Statements (cross-ref from II Schedule B Summary, Column per General Ledger ) $                   -



              Expenses Reconciled To IRS Form 990, if applicable


                                                              Total Reported Program EXPENSE (from II Schedule B Summary ) $                             -

                                                                               + Reported Indirect Expense per Summary Schedule $                        -

              Exp Item 1 (Please describe) - If you do not prepare the IRS Form 990, describe as NA
              Exp Item 2                                                                                                             $                   -
              Exp Item 3                                                                                                                                 -
              Exp Item 4                                                                                                                                 -
              Exp Item 5                                                                                                                                 -
              Exp Item 6                                                                                                                                 -
                                                                     EXPENSES reconciled to $ reported on IRS Form 990, if applicable $                  -

              Expenses (per IRS Form 990, if applicable) Reconciled To Financial Statements

              Exp Item 1 (Please describe) (for example: Unallowable expenses that you extracted)                                    $                   -
              Exp Item II                                                                                                                                -
              Exp Item III                                                                                                                               -
              Exp Item IV                                                                                                                                -
              Exp Item V                                                                                                                                 -
              Exp Item VI                                                                                                                                -

                                                                                Total Reconciled Expense per Financial Statements $                      -

                                EXPENSES per Financial Statements (cross-ref from II Schedule B Summary, Column per General Ledger ) $                   -




              Average Monthly Salary, Wages & Benefits for Direct Care Program Personnel {Annual $/FTE/12}                           $                   -




              Average Monthly Salary, Wages & Benefits for Program Staff Supervising Direct Care Personnel {Annual $/FTE/12}         $                   -




                                                                                                                                           III Sch C Recon990_ FS_ProgSW {Page 20 of 22}
PROVIDER COSTS WORKSHEETS                                                                                                     IId SchA ProgDISREGARD                                                                                                                       Draft [Pg. 21 of 22]

       FEIN     0
       CM C1    CM C2                                                            CM C3                      CM C4                        CM C5                    CM C6                      CM C7                       CM C8                                     CM C9
                                                                                                                                                                                                                SOURCE OF FUNDS: Other
                                                                            SOURCE OF FUNDS:           SOURCE OF FUNDS:        SOURCE OF FUNDS: Other        SOURCE OF FUNDS:       SOURCE OF FUNDS: Private                                  Comments (Please Identify the Col # to
       Line #   Description                                                                                                                                                                                      Rev & Exp [such as Other
                                                                                Medicaid                   Medicare             State Issued Non-Medicaid       City / Town             Funds e.g., Grants                                       which the Comment applies)
                                                                                                                                                                                                                       Insurance]
       0010     Agency: Funding Source (eg DHS, MHRH etc)

       0015     Program (eg Day, Asst.Lvg, HmHlth)                                                                        -                              -                      -                           -                             -

       0020     Provider Type
                # of Units of Service (Clarify Units TYPE in Comments                                                                                                                                                                         Clarify Units Type
       0030                                                                                -                          -                              -                     -                            -                             -
                Column: Hrs, Days, etc)
                Total Units (Clarify Units TYPE in Comments Column:                                                                                                                                                                           Clarify Units Type
       0040
                Hrs, Days, etc)                                                            -                          -                              -                     -                            -                             -
       0050     % of Units
                Staffing (Full Time Equiv: Payroll Hrs @ 1820
       0060
                hrs/yr)
       0100     REV Grants, Gifts, etc.                                 $                      -   $                      -    $                         -   $                  -    $                      -   $                         -
       0200     REV Program Revenue                                                            -                                                                                -                           -                             -
       0225     REV Copays
       0250     REV Contracts
       0300     REV Dues, Fees, Assessments
       0400     REV Interest
       0500     REV Investment Income
       0600     REV Rental income
       0800     REV Sale of Assets
       0900     REV Events, Activities
       1000     REV Sale of Inventory (net)
       1100     REV Other Revenue
       1200     REVENUE Total                                           $                      -   $                      -    $                         -   $                  -    $                      -   $                         -                                       -
                EXP Officers, Directors, Key Emp. Compensation
       2500                                                             $                      -   $                      -    $                         -   $                  -    $                      -   $                         -
                [This Program ONLY]
       2505     EXP PR Tax, Benefits & Wkr Comp Ln2500
                EXP Mgmt & Admin Sal. (not in Ln 2500) [This
       2550                                                                                                                                                                                                                               -
                program ONLY]
       2555     EXP PR Tax, Benefits & Wkr Comp Ln 2550                                                                                                                                                                                   -
                EXP Sal/Wages - Direct Care Program staff (not in
       2600                                                                                                                                                                                                                               -
                above) [This program ONLY]
                EXP Sal/Wages - Rehab/Therapy Program staff
       2601
                (not in above) [This program ONLY]
                EXP Sal/Wages - Professional Oversight staff (not
       2602                                                                                                                                                                                                                               -
                in above) [This program ONLY]
       2605     EXP PR Tax,Ben.,Wkr Comp [Ln 2600..2602]                                                                                                                                                                                  -
                EXP Other Compensation (not in above) [This
       2700
                program ONLY]
                EXP Employee Benefits (not in above) [This
       2800                                                                                                                                                                                                                               -
                program ONLY]
                EXP Payroll Taxes (not in above) [This program
       2900
                ONLY]
                EXP Workers Comp (not in above) [This program
       2910
                ONLY]
       3000     EXP Fundraising & Events




                                                                                                                                                                                                                                                              IId SchA ProgDISREGARD {Page 21 of 22}
PROVIDER COSTS WORKSHEETS                                                                                                 IId SchA ProgDISREGARD                                                                                                             Draft [Pg. 22 of 22]

       FEIN     0
       CM C1    CM C2                                                        CM C3                      CM C4                        CM C5                   CM C6                      CM C7                      CM C8                             CM C9
                                                                                                                                                                                                          SOURCE OF FUNDS: Other
                                                                        SOURCE OF FUNDS:           SOURCE OF FUNDS:        SOURCE OF FUNDS: Other       SOURCE OF FUNDS:       SOURCE OF FUNDS: Private                               Comments (Please Identify the Col # to
       Line #   Description                                                                                                                                                                                Rev & Exp [such as Other
                                                                            Medicaid                   Medicare             State Issued Non-Medicaid      City / Town             Funds e.g., Grants                                    which the Comment applies)
                                                                                                                                                                                                                 Insurance]
       3100     EXP Accounting
       3200     EXP Legal
       3220     EXP Contract Personnel - Program
       3240     EXP Contract Personnel - Admin/Support
       3300     EXP Supplies
       3400     EXP Utilities: Tel., Elec., Heat, etc.
       3600     EXP Facilities Rent, Lease & Repairs
       3700     EXP Equipment Rent, Lease & Repairs
       3900     EXP Travel, Conferences
       4100     EXP Interest
       4200     EXP Depreciation
       4310     EXP Insurance: Property, Liability
       4320     EXP Advertising - Help Wanted                                                                                                                                                                                     -
       4330     EXP Advertising: Promotional, PR, Lobbying
       4340     EXP Bad Debt
       4350     EXP Other (such as BCI) ______________
       4355     EXP Other ______________
       4360     EXP Other ______________
       4365     EXP Other ______________
       4370     EXP Other ______________

       4380     EXP Allocated Indirect Exp [Rev % of Ttl.Rev]

       4400     EXP Total                                           $                      -   $                      -    $                        -   $                  -    $                    -    $                       -                                     -
       4450     NET of Revenue-Expense                              $                      -   $                      -    $                        -   $                  -    $                    -    $                       -                                     -

       4500     Cash & Short-term Investments
       4550     Other Current Assets
       5900     Total Assets
       6000     Current Liabilities
       6600     Total Liabilities
       6650     Net Assets, Equity or Fund Balance
       6700     Fund Balance: Unrestricted
       6800     Fund Balance: Temporarily Restricted
       6900     Fund Balance: Permanently Restricted

                                                                0




                                                                                                                                                                                                                                                   IId SchA ProgDISREGARD {Page 22 of 22}

								
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