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					                                                      NC Department of Health and Human Services
                                                            Division of Medical Assistance


                                         2008 Mental Health Residential Treatment Cost Report                                           SCHEDULE A
                                                                                                           Reporting Basis
                                                                  Part I - General                   Cash                              Accrual
1.     Fiscal Year Ending Date:                                                9.   LICENSED BED Capacity for Agency by Type of Care:
2.     Federal Tax ID#:                                                                           Non-Treatment BEDS
3.     Corporate Name:                                                                  Family Setting                  Program/Group Setting
       Street or P.O.:                                                         Family
       City, State, Zip:                                                       Foster                                  Residential Care
4.     Name of Contact Person/Director/Administrator                                                      Treatment BEDS
                                                                                        Family Setting                  Program/Group Setting
5.     Telephone No.                                             Ext:           Therapeutic Foster             Level II                     PRTF
6.     Email Address:                                                                                          Level III               Other MH
7.     Fax Number:                                                                                             Level IV
8. # of Months in Operation during reporting period:                           10. Total Number of Facilities:
          From:                            To:
                                                                 Part II - Tax Information
11. Entity Type:                 12. Tax Status                                13. Organizational Structure
       Government                                   Non-profit                      Sole proprietorship                      Partnership
       Private                                      For profit                      Corporation                              Other

                                                                 Part III - Resident Days
                                                                  Non-Treatment DAYS
14. Total Number of Non-Treatment Resident Census Days:                                        Family Foster                   Residential Care
15. Total LICENSED Bed Days Available for Non-Treatment Resident Care:                         Family Foster                   Residential Care
15a.Total AVAILABLE Bed Days for Non-Treatment Resident Care:                                  Family Foster                   Residential Care
                                                                     Treatment DAYS
16. Total Number of Treatment Days:
       Family Setting                                                         Program/Group Setting
       Therapeutic
         Foster                  Level II                Level III                  Level IV                       PRTF                Other MH
17.          Total LICENSED Bed Days Available for Treatment:                  17a.          Total AVAILABLE Bed Days for Treatment:
        Family Setting            Program/Group Setting                          Family Setting             Program/Group Setting
                                    Level II                 PRTF                                                Level II                   PRTF
       Therapeutic                                                             Therapeutic
         Foster                    Level III             Other MH                Family                          Level III             Other MH

                                   Level IV                                                                      Level IV
                                                        Part IV - Certification of Accuracy
The undersigned individual (company) does hereby state that the report forms (Schedule A, A-1, B, C, C-1, C-2, and D) have been prepared from
accounting records of the facility and are accurate based on recorded information and information provided.
     Chief Executive/Agency
         Official's Signature:                                                                                                 Date:

         Auditor's Signature:                                                                                                  Date:

Auditor's Phone Number:

        Preparer's Signature                                                                                                   Date:
           Preparer's Phone
                    Number:

           DMA Rate Setting                                                                                   bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
           Updated: September 28, 2007                                    1 of 15                                                             Sched A
                                             N C DEPARTMENT OF HEALTH AND HUMAN SERVICES
                                                     DIVISION OF MEDICAL ASSISTANCE


                                2008 MENTAL HEALTH RESIDENTIAL TREATMENT COST REPORT
                                                                                                                     SCHEDULE A-1
Federal Tax ID #                     0

Corporate Name:                          0
Multiple Sites 1 - 4
1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH




       DMA Rate Setting
       Updated: September 28, 2007                                                               bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                              Page 2 of 15                                                   Schedule A-1
                                             N C DEPARTMENT OF HEALTH AND HUMAN SERVICES
                                                     DIVISION OF MEDICAL ASSISTANCE
                                                                                                                     SCHEDULE A-1
Federal Tax ID #                     0

Corporate Name:                          0
Multiple Sites 5 - 8
1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH




       DMA Rate Setting
       Updated: September 28, 2007                                                               bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                              Page 3 of 15                                                   Schedule A-1
                                             N C DEPARTMENT OF HEALTH AND HUMAN SERVICES
                                                     DIVISION OF MEDICAL ASSISTANCE
                                                                                                                     SCHEDULE A-1
Federal Tax ID #                     0

Corporate Name:                          0
Multiple Sites 9 - 12
1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH

1. Name of Facility:                                                         6. RESIDENT or OCCUPIED DAYS:

  Street or P.O.:                                                                            Non-Treatment DAYS:

  City, State, Zip Code:                                                     Family Foster                  Residential Care
2. Current Medicaid
Provider #:                                                                                    Treatment DAYS:

3. Prior Medicaid                                                            Therapeutic
                                                                             Foster Care         Level II            Level III
Provider Number:
4. Level of Care:
5. Licensed Bed                                                                                                        Other
                                                                                  Level IV        PRTF
Capacity for this facility:                                                                                              MH




       DMA Rate Setting
       Updated: September 28, 2007                                                               bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                              Page 4 of 15                                                   Schedule A-1
                                   N C DEPARTMENT OF HEALTH AND HUMAN SERVICES
                                           DIVISION OF MEDICAL ASSISTANCE


                   2008 MENTAL HEALTH RESIDENTIAL TREATMENT COST REPORT
                                                                     SCHEDULE B
Federal Tax ID:           0
Corporate Name: 0
Audit Year:       1/0/1900

REVENUE:

1.    MEDICAID
      a. HRI-R
      b. CAP-MR
      c. Other Medicaid
2.    TOTAL MEDICAID                                                                      $                           -


3.    OTHER FEDERAL FUNDS
      a. IV-E Funds
      b. IV-B Funds
      c. Federal Grants
      d. USDA School Food Service
      e. All Other Federal Funds
4.    TOTAL OTHER FEDERAL FUNDS                                                           $                           -


5.    STATE FUNDS
      a. State Funds (Old Grant-in-Aide)
      b. JJDP Funds
      c. Non-Medicaid covered treatment (including At Risk)
      d. State Training Funds
      e. Non IV-E Foster Care Funds (SFHF)
      f. All Other State Funds (including State Grants)
6.    TOTAL STATE FUNDS                                                                   $                           -


7.     COUNTY FUNDS
8.     INVESTMENT INCOME
9.     PRIVATE CONTRIBUTIONS
10.    OTHER
11.    TOTAL REVENUE (Total of Lines 2,4,6,7,8,9,10)                                      $                           -
12.    LESS: TOTAL EXPENSES
13.    NET PROFIT (LOSS)                                                                  $                           -




DMA Rate Setting                                                                 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Updated: September 28, 2007                               5 of 15                                     Schedule B-Revenue
                                                                                                                                                                                                        NC Department of Health and Human Services
                                                                                                                                                                                                                Division of Medical Assistance


                                                                                                                                                                                         2008 Mental Health Residential Treatment Cost Report

                                                                                                                                                                                                                                MENTAL HEALTH RESIDENTIAL R&B
SCHEDULE C - Expenses                                                                                        MENTAL HEALTH RESIDENTIAL TREATMENT                                                                    (INCLUDING NON-IV-E ELIGIBLE THERAPEUTIC FOSTER HOME)                                                                                                     ADMINISTRATION
Tax ID:             0                                                                                                                                                                          OTHER                   Room &                     Room &                Room &                Room &              THERAPEUTIC
Corporate Name                                                 -          MHL                      MHL                      MHL                      MHL                   PRTF               CAP MR                    Board                      Board                 Board                 Board                FAMILY                                                  MEDICAID                                                TOTAL
Audit Date:         1/0/00                                             RESIDENTIAL              RESIDENTIAL              RESIDENTIAL              RESIDENTIAL                                ICF MR, etc.            RESIDENTIAL                RESIDENTIAL           RESIDENTIAL           RESIDENTIAL             FOSTER                OTHER        FUND-     Covered               Non-Covered        NON-MEDICAID
                                                                         LEVEL l                  LEVEL ll                LEVEL lll                LEVEL lV                                                            LEVEL l                    LEVEL ll             LEVEL lll             LEVEL IV             Room & Board           PROGRAM       RAISING   Services               Services          Services Admin
                                                                           1                         2                       3                        4                     5                     6                      7                           8                    9                     10                    11                   12            13        14a                    14b                   15                   16

1     Position Count/FTE's per category                                              0.00                     0.00                     0.00                     0.00              0.00          0.00                                                                                                                                                                                                                                        -

MEDICAID TREATMENT EXPENSES:

2a    Salaries and Wages - Paraprofessional Staff                  $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

      Salaries and Wages - Licensed Professional Staff (LP)
2b    (may also include Qualified Professional Staff (QP)          $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

2c    Salaries and Wages - Associate Professional Staff (AP)       $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

3     Employee Benefit Program                                     $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

4     Payroll Taxes                                                $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

5     TOTAL SALARIES & RELATED EXPENSES                            $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

6     Medicaid Supplies                                            $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

7     Contract Labor                                               $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -
      Bloodborne Pathogen (OSHA) for Medicaid Program
8     FTE's                                                        $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -
      Employee Criminal Records Check Fees for Medicaid
9     FTE's                                                        $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

10    Other                                                        $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

11    TOTAL MEDICAID TREATMENT EXPENSES                            $                   -    $                   -    $                   -    $                   -    $            -    $                  -                                                                                                                                                                                                               $                   -

12    TOTAL MEDICAID RESIDENT DAYS PROVIDED                                            -                        -                        -                        -                 -                       -                                                                                                                                                                                                                                   -
 PROGRAM EXPENSES for Room and Board, and
              Supervision
Salary Expenses (Do not include Social Work or Admin
Salary)

13    Salaries and Wages                                                                                                                                               $            -    $                  -                                                                                                                                                                                                               $                   -

14    Employee Benefit Program                                                                                                                                         $            -    $                  -                                                                                                                                                                                                               $                   -

15    Payroll Taxes                                                                                                                                                    $            -    $                  -                                                                                                                                                                                                               $                   -

16    TOTAL SALARIES & RELATED EXPENSES                                                                                                                                $            -    $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -                                                                        $                   -

Social Services Salary Expense (Do Not Include Admin)

17    Salaries and Wages                                                                                                                                               $            -    $                  -                                                                                                                                                                                                               $                   -

18    Employee Benefit Program                                                                                                                                         $            -    $                  -                                                                                                                                                                                                               $                   -

19    Payroll Taxes                                                                                                                                                    $            -    $                  -                                                                                                                                                                                                               $                   -

20    TOTAL SOCIAL SERVICES SALARY EXPENSE                                                                                                                             $            -    $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -                                                                        $                   -

HOUSEKEEPING/SHELTER COST

21    Cleaning Supplies                                                                                                                                                $            -    $                  -                                                                                                                                                                                                               $                   -

22    Outside Laundry Service                                                                                                                                          $            -    $                  -                                                                                                                                                                                                               $                   -

23    Utilities                                                                                                                                                        $            -    $                  -                                                                                                                                                                                                               $                   -

24    Repair & Maintenance Building & Grounds                                                                                                                          $            -    $                  -                                                                                                                                                                                                               $                   -

25    Repair & Maintenance Equipment                                                                                                                                   $            -    $                  -                                                                                                                                                                                                               $                   -

26    Sanitation & Pest Control                                                                                                                                        $            -    $                  -                                                                                                                                                                                                               $                   -

27    Rent- Facility                                                                                                                                                   $            -    $                  -                                                                                                                                                                                                               $                   -

28    Rent-Buildings/Land                                                                                                                                              $            -    $                  -                                                                                                                                                                                                               $                   -

29    Linen & Bedding                                                                                                                                                  $            -    $                  -                                                                                                                                                                                                               $                   -

30    Equipment                                                                                                                                                        $            -    $                  -                                                                                                                                                                                                               $                   -

31    Miscellaneous                                                                                                                                                    $            -    $                  -                                                                                                                                                                                                               $                   -



                                                                                                                                                                                                                             Page 6 of 15
              DMA Rate Setting
              Updated: September 28, 2007                                                                                                                                                                                                                                                                                                                                                       bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                                                                                                                                                                                                                                                                                                                    Schedule C-Expenses
                                                                                                                                                     NC Department of Health and Human Services
                                                                                                                                                             Division of Medical Assistance


                                                                                                                                                                             MENTAL HEALTH RESIDENTIAL R&B
SCHEDULE C - Expenses                                                               MENTAL HEALTH RESIDENTIAL TREATMENT                                          (INCLUDING NON-IV-E ELIGIBLE THERAPEUTIC FOSTER HOME)                                                                                                     ADMINISTRATION
Tax ID:             0                                                                                                                       OTHER                   Room &                     Room &                Room &                Room &              THERAPEUTIC
Corporate Name                                       -      MHL           MHL                 MHL           MHL            PRTF            CAP MR                    Board                      Board                 Board                 Board                FAMILY                                                  MEDICAID                                                TOTAL
Audit Date:         1/0/00                               RESIDENTIAL   RESIDENTIAL         RESIDENTIAL   RESIDENTIAL                      ICF MR, etc.            RESIDENTIAL                RESIDENTIAL           RESIDENTIAL           RESIDENTIAL             FOSTER                OTHER        FUND-     Covered               Non-Covered        NON-MEDICAID
                                                           LEVEL l       LEVEL ll           LEVEL lll     LEVEL lV                                                  LEVEL l                    LEVEL ll             LEVEL lll             LEVEL IV             Room & Board           PROGRAM       RAISING   Services               Services          Services Admin
                                                             1              2                  3             4              5                  6                      7                           8                    9                     10                    11                   12            13        14a                    14b                   15                   16


32    TOTAL HOUSEKEEPING /SHELTER COST                                                                                 $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -                                                                        $               -

DIETARY/FOOD COST

33    Food                                                                                                             $          -   $                  -                                                                                                                                                                                                               $               -

34    Dietary Supplies/Equipment                                                                                       $          -   $                  -                                                                                                                                                                                                               $               -

35    Miscellaneous                                                                                                    $          -   $                  -                                                                                                                                                                                                               $               -

36    TOTAL DIETARY/FOOD COST                                                                                          $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -                                                                        $               -

PERSONAL INCIDENTALS

37    Clothing                                                                                                         $          -   $                  -                                                                                                                                                                                                               $               -

38    Personal Hygiene Items                                                                                           $          -   $                  -                                                                                                                                                                                                               $               -

39    Medical Supplies                                                                                                 $          -   $                  -                                                                                                                                                                                                               $               -

40    Physician Fees & Hospitalization                                                                                 $          -   $                  -                                                                                                                                                                                                               $               -

41    Non-Legend Drugs and Medical Services                                                                            $          -   $                  -                                                                                                                                                                                                               $               -

42    Beauty and Barber Shop                                                                                           $          -   $                  -                                                                                                                                                                                                               $               -

43    Miscellaneous                                                                                                    $          -   $                  -                                                                                                                                                                                                               $               -


44    TOTAL PERSONAL NEED COSTS/CLOTHING                                                                               $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -                                                                        $               -

45    RECREATIONAL COST -- Therapeutic Recreation                                                                      $          -   $                  -                                                                                                                                                                                                               $               -

46    EDUCATIONAL COST - School Supplies                                                                               $          -   $                  -                                                                                                                                                                                                               $               -

TRANSPORTATION COST

47    Transportation for Family Visitation                                                                             $          -   $                  -                                                                                                                                                                                                               $               -

48    Travel Cost                                                                                                      $          -   $                  -                                                                                                                                                                                                               $               -

49    Miscellaneous                                                                                                    $          -   $                  -                                                                                                                                                                                                               $               -

50    TOTAL TRANSPORTATION COST                                                                                        $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -                                                                        $               -

51    Foster Care Board Payments to Foster Parents                                                                                                                                                                                                                                                                                                                       $               -


52    TOTAL ROOM & BOARD EXPENSE                                                                                       $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -                                                                        $               -

OTHER COSTS

53    Office Supplies                                                                                                  $          -   $                  -                                                                                                                                                                                                               $               -

54    Insurance - Vehicle                                                                                              $          -   $                  -                                                                                                                                                                                                               $               -

55    Insurance - Fixed Assets                                                                                         $          -   $                  -                                                                                                                                                                                                               $               -

56    Insurance - General                                                                                              $          -   $                  -                                                                                                                                                                                                               $               -

57    Automobile & Truck Maintenance                                                                                   $          -   $                  -                                                                                                                                                                                                               $               -

58    Telephone                                                                                                        $          -   $                  -                                                                                                                                                                                                               $               -

59    Postage                                                                                                          $          -   $                  -                                                                                                                                                                                                               $               -

60    Dues & Subscriptions                                                                                             $          -   $                  -                                                                                                                                                                                                               $               -

61    Legal & Accounting                                                                                               $          -   $                  -                                                                                                                                                                                                               $               -

62    Interest - Automobile                                                                                            $          -   $                  -                                                                                                                                                                                                               $               -

63    Interest - Mortgage                                                                                              $          -   $                  -                                                                                                                                                                                                               $               -

64    Interest - Fixed Assets                                                                                          $          -   $                  -                                                                                                                                                                                                               $               -

65    Interest - Operating                                                                                             $          -   $                  -                                                                                                                                                                                                               $               -

66    Audit                                                                                                            $          -   $                  -                                                                                                                                                                                                               $               -

67    Rent - Automotive/Equipment                                                                                      $          -   $                  -                                                                                                                                                                                                               $               -

                                                                                                                                                                          Page 7 of 15
              DMA Rate Setting
              Updated: September 28, 2007                                                                                                                                                                                                                                                                                                    bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                                                                                                                                                                                                                                                                 Schedule C-Expenses
                                                                                                                                                                                               NC Department of Health and Human Services
                                                                                                                                                                                                       Division of Medical Assistance


                                                                                                                                                                                                                       MENTAL HEALTH RESIDENTIAL R&B
SCHEDULE C - Expenses                                                                                         MENTAL HEALTH RESIDENTIAL TREATMENT                                                          (INCLUDING NON-IV-E ELIGIBLE THERAPEUTIC FOSTER HOME)                                                                                                                 ADMINISTRATION
Tax ID:             0                                                                                                                                                                 OTHER                   Room &                     Room &                Room &                Room &              THERAPEUTIC
Corporate Name                                                     -          MHL                   MHL                     MHL                   MHL                PRTF            CAP MR                    Board                      Board                 Board                 Board                FAMILY                                                              MEDICAID                                                  TOTAL
Audit Date:         1/0/00                                                 RESIDENTIAL           RESIDENTIAL             RESIDENTIAL           RESIDENTIAL                          ICF MR, etc.            RESIDENTIAL                RESIDENTIAL           RESIDENTIAL           RESIDENTIAL             FOSTER                OTHER            FUND-             Covered               Non-Covered           NON-MEDICAID
                                                                             LEVEL l               LEVEL ll               LEVEL lll             LEVEL lV                                                      LEVEL l                    LEVEL ll             LEVEL lll             LEVEL IV             Room & Board           PROGRAM           RAISING           Services               Services             Services Admin
                                                                               1                      2                      3                     4                  5                  6                      7                           8                    9                     10                    11                   12                13                14a                    14b                     15                   16

68    Rent - Office                                                                                                                                              $          -   $                  -                                                                                                                                                                                                                                 $           -

69    Real Estate Taxes                                                                                                                                          $          -   $                  -                                                                                                                                                                                                                                 $           -

70    Data Processing                                                                                                                                            $          -   $                  -                                                                                                                                                                                                                                 $           -

71    Travel & Entertainment                                                                                                                                     $          -   $                  -                                                                                                                                                                                                                                 $           -

72    Licenses for individuals                                                                                                                                   $          -   $                  -                                                                                                                                                                                                                                 $           -

73    Licenses for facility                                                                                                                                      $          -   $                  -                                                                                                                                                                                                                                 $           -

74    Bloodborne Pathogen (OSHA) for Non-Medicaid FTE's                                                                                                          $          -   $                  -                                                                                                                                                                                                                                 $           -
      Employee Criminal Records Check Fees for Non-
75    Medicaid FTE's                                                                                                                                             $          -   $                  -                                                                                                                                                                                                                                 $           -

76    Management Services                                                                                                                                        $          -   $                  -                                                                                                                                                                                                                                 $           -

77    Advertising                                                                                                                                                $          -   $                  -                                                                                                                                                                                                                                 $           -

78    Printing                                                                                                                                                   $          -   $                  -                                                                                                                                                                                                                                 $           -
      Meetings/Seminars/Training (Include Operations
79    Personnel Costs to set up)                                                                                                                                 $          -   $                  -                                                                                                                                                                                                                                 $           -

80    Miscellaneous                                                                                                                                              $          -   $                  -                                                                                                                                                                                                                                 $           -

81    Salaries and Other Expenses including Admin.                                                                                                               $          -   $                  -                                                                                                                                                                                                                                 $           -

82    TOTAL OTHER COSTS                                                                                                                                          $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -   $             -   $                -   $                  -   $                    -   $           -

83    TOTAL EXPENSES BEFORE DEPRECIATION                               $                 -   $                   -   $                 -   $                 -   $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -   $             -   $                -   $                  -   $                    -   $           -


DEPRECIATION

84    Depreciation - Building & Improvement - Office                                                                                                             $          -   $                  -                                                                                                                                                                                                                                 $           -

85    Depreciation - Automotive                                                                                                                                  $          -   $                  -                                                                                                                                                                                                                                 $           -

86    Depreciation - Equipment                                                                                                                                   $          -   $                  -                                                                                                                                                                                                                                 $           -

87    TOTAL DEPRECIATION                                                                                                                                         $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -   $             -   $                -   $                  -   $                    -   $           -


88    TOTAL RATE SETTING EXPENSES                                      $                 -   $                  -    $                 -   $                 -   $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -   $             -   $               -    $                  -   $                    -   $           -

NON-ALLOWABLE EXPENSES

89    Child Development                                                                                                                                          $          -   $                  -                                                                                                                                                                                                                                 $           -

90    Other Child and Family Services                                                                                                                            $          -   $                  -                                                                                                                                                                                                                                 $           -

91    Higher Education                                                                                                                                           $          -   $                  -                                                                                                                                                                                                                                 $           -

92    Bad Debts                                                                                                                                                  $          -   $                  -                                                                                                                                                                                                                                 $           -

93    Multi-Purpose Group Home                                                                                                                                   $          -   $                  -                                                                                                                                                                                                                                 $           -

94    Miscellaneous & Non-Allowable costs -Medicaid                                                                                                              $          -   $                  -                                                                                                                                                                                                                                 $           -

95    In Kind Donations / Contributions                                                                                                                          $          -   $                  -                                                                                                                                                                                                                                 $           -

96    Penalties                                                                                                                                                  $          -   $                  -                                                                                                                                                                                                                                 $           -

97    Extraordinary Items                                                                                                                                                                                                                                                                                                                                                                                                            $           -

98    TOTAL NON-ALLOWABLE EXPENSES                                                                                                                               $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -   $             -   $                -   $                  -   $                    -   $           -

99a   TOTAL TO MATCH AUDIT (Line 88 plus line 98)                      $                 -   $                  -    $                 -   $                 -   $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -   $             -   $               -    $                  -   $                    -   $           -

99b   SCHEDULE B TOTAL EXPENSE FROM LINE 12:                                                                                                                                                                                                                                                                                                                                                                                         $           -
      DIFFERENCE:(TOTAL COLUMN, LN 99) LESS (SCHEDULE B TOTAL
99c   EXPENSE FROM LINE 12)                                                                                                                                                                                                                                                                                                                                                                                                          $           -

100   TOTAL RESIDENT DAYS PROVIDED                                                       -                      -                      -                     -              -                      -

          TOTAL PROGRAM EXPENSES ALLOWED                   (excludes
101                     non Medicaid allowed line items)               $                 -   $                  -    $                 -   $                 -   $          -   $                  -   $                    -      $                 -   $                 -   $                 -   $                  -   $             -   $             -   $               -    $                  -   $                    -   $           -




                                                                                                                                                                                                                    Page 8 of 15
              DMA Rate Setting
              Updated: September 28, 2007                                                                                                                                                                                                                                                                                                                                                          bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                                                                                                                                                                                                                                                                                                                       Schedule C-Expenses
                                                                                                                             NC Department of Health and Human Services
                                                                                                                                      Division of Medical Assistance

                                                                                                           2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID:             0                                                    Mental              Foster Care            Therapeutic             BHLTR                  BHLTR               BHLTR               BHLTR
Corporate Name      0                                                   Health Svc           Therapeutic            Behavioral             4 Beds or              5 Beds or           4 Beds or           5 Beds or                             OTHER
Audit Date:         1/0/1900                                                                    Child                Services                Less                   More                Less                More                                CAP MR,
                                                                         LEVEL l              LEVEL ll               LEVEL ll              LEVEL lll              LEVEL lll           LEVEL lV            LEVEL lV            PRTF            ICF MR, etc.
                                                                          H0046                S5145                  H2020                  H0019                  H0019               H0019               H0019                                                       TOTAL

                                                                            1                     2                      3                      4                      5                  6                   7                8                    9                     10

1         Position Count/FTE's per category                                                                                                                                                                                                                                         -

                  MEDICAID TREATMENT EXPENSES

2a        Salaries and Wages - Paraprofessional Staff                                                                                                                                                                                                             $                     -

          Salaries and Wages - Licensed Professional Staff (LP)
2b        (may also include Qualified Professional Staff (QP)                                                                                                                                                                                                     $                     -

2c        Salaries and Wages - Associate Professional Staff (AP)                                                                                                                                                                                                  $                     -

3         Employee Benefit Program                                                                                                                                                                                                                                $                     -

4         Payroll Taxes                                                                                                                                                                                                                                           $                     -

5         TOTAL SALARIES AND RELATED EXPENSES                       $                -   $                  -   $                 -    $                  -   $               -   $               -   $               -   $          -    $                   -   $                     -

6         Medicaid Supplies                                                                                                                                                                                                                                       $                     -

7         Contract Labor                                                                                                                                                                                                                                          $                     -

8         Bloodborne Pathogen (OSHA) for Medicaid Program FTE's                                                                                                                                                                                                   $                     -

9         Employee Criminal Records Check Fees for Medicaid FTE's                                                                                                                                                                                                 $                     -

10        Other                                                                                                                                                                                                                                                   $                     -

11        TOTAL MEDICAID TREATMENT EXPENSES                         $                -   $                  -   $                 -    $                  -   $               -   $               -   $               -   $          -    $                   -   $                     -

12        TOTAL MEDICAID RESIDENT DAYS PROVIDED                                                                                                                                                                                                                                     -
     PROGRAM EXPENSES for Room and Board, and
                  Supervision

Salary Expenses (Do not include Social Work or Admin Salary)

13        Salaries and Wages                                                                                                                                                                                                                                      $                     -

14        Employee Benefit Program                                                                                                                                                                                                                                $                     -

15        Payroll Taxes                                                                                                                                                                                                                                           $                     -

16        TOTAL SALARIES AND RELATED EXPENSES                                                                                                                                                                             $          -    $                   -   $                     -

Social Services Salary Expense (Do not include Admin)                                                                                                                                                                                                             $                     -

17        Salaries and Wages                                                                                                                                                                                                                                      $                     -

18        Employee Benefit Program                                                                                                                                                                                                                                $                     -

19        Payroll Taxes                                                                                                                                                                                                                                           $                     -

20        TOTAL SOCIAL SERVICES SALARY EXPENSE                                                                                                                                                                            $          -    $                   -   $                     -

HOUSEKEEPING/SHELTER COST

          DMA Rate Setting
          Updated: September 28, 2007                                                                                                                                                                                                    bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                                               Page 9 of 15                                                                                      Sched C-1 Medicaid HRI-R Codes
                                                                                                NC Department of Health and Human Services
                                                                                                       Division of Medical Assistance

                                                                                  2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID:              0                                  Mental      Foster Care        Therapeutic           BHLTR                 BHLTR       BHLTR       BHLTR
Corporate Name       0                                 Health Svc   Therapeutic        Behavioral           4 Beds or             5 Beds or   4 Beds or   5 Beds or                         OTHER
Audit Date:          1/0/1900                                          Child            Services              Less                  More        Less        More                            CAP MR,
                                                        LEVEL l      LEVEL ll           LEVEL ll            LEVEL lll             LEVEL lll   LEVEL lV    LEVEL lV        PRTF            ICF MR, etc.
                                                         H0046        S5145              H2020                H0019                 H0019       H0019       H0019                                                   TOTAL

                                                           1             2                  3                    4                      5         6           7            8                    9                     10

21       Cleaning Supplies                                                                                                                                                                                    $                 -

22       Outside Laundry Service                                                                                                                                                                              $                 -

23       Utilities                                                                                                                                                                                            $                 -

24       Repair & Maintenance Building & Grounds                                                                                                                                                              $                 -

25       Repair & Maintenance Equipment                                                                                                                                                                       $                 -

26       Sanitation & Pest Control                                                                                                                                                                            $                 -

27       Rent- Facility                                                                                                                                                                                       $                 -

28       Rent-Buildings/Land                                                                                                                                                                                  $                 -

29       Linen & Bedding                                                                                                                                                                                      $                 -

30       Equipment                                                                                                                                                                                            $                 -

31       Miscellaneous                                                                                                                                                                                        $                 -



32       TOTAL HOUSEKEEPING /SHELTER COST                                                                                                                             $          -    $                   -   $                 -

DIETARY/FOOD COST

33       Food                                                                                                                                                                                                 $                 -

34       Dietary Supplies/Equipment                                                                                                                                                                           $                 -

35       Miscellaneous                                                                                                                                                                                        $                 -

36       TOTAL DIETARY/FOOD COST                                                                                                                                      $          -    $                   -   $                 -

PERSONAL NEED COSTS/CLOTHING

37       Clothing                                                                                                                                                                                             $                 -

38       Personal Hygiene Items                                                                                                                                                                               $                 -

39       Medical Supplies                                                                                                                                                                                     $                 -

40       Physician Fees & Hospitalization                                                                                                                                                                     $                 -

41       Non-Legend Drugs and Medical Services                                                                                                                                                                $                 -

42       Beauty and Barber Shop                                                                                                                                                                               $                 -

43       Miscellaneous                                                                                                                                                                                        $                 -

44       TOTAL PERSONAL NEED COSTS/CLOTHING                                                                                                                           $          -    $                   -   $                 -

45       RECREATIONAL COST -- Therapeutic Recreation                                                                                                                                                          $                 -

         DMA Rate Setting
         Updated: September 28, 2007                                                                                                                                                 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                Page 10 of 15                                                                Sched C-1 Medicaid HRI-R Codes
                                                                                                 NC Department of Health and Human Services
                                                                                                        Division of Medical Assistance

                                                                                   2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID:            0                                     Mental      Foster Care        Therapeutic           BHLTR                 BHLTR       BHLTR       BHLTR
Corporate Name     0                                    Health Svc   Therapeutic        Behavioral           4 Beds or             5 Beds or   4 Beds or   5 Beds or                         OTHER
Audit Date:        1/0/1900                                             Child            Services              Less                  More        Less        More                            CAP MR,
                                                         LEVEL l      LEVEL ll           LEVEL ll            LEVEL lll             LEVEL lll   LEVEL lV    LEVEL lV        PRTF            ICF MR, etc.
                                                          H0046        S5145              H2020                H0019                 H0019       H0019       H0019                                                   TOTAL

                                                            1             2                  3                    4                      5         6           7            8                    9                     10

46       EDUCATIONAL COST - School Supplies                                                                                                                                                                    $                 -

TRANSPORTATION COST

47       Transportation for Family Visitation                                                                                                                                                                  $                 -

48       Travel Cost

49       Miscellaneous                                                                                                                                                                                         $                 -


50       TOTAL TRANSPORTATION COST                                                                                                                                     $          -    $                   -   $                 -


51       Foster Care Board Payments to Foster Parents


52       Total Room & Board Expense                                                                                                                                    $          -    $                   -   $                 -
OTHER COSTS

53       Office Supplies                                                                                                                                                                                       $                 -

54       Insurance - Vehicle                                                                                                                                                                                   $                 -

55       Insurance - Fixed Assets                                                                                                                                                                              $                 -

56       Insurance - General                                                                                                                                                                                   $                 -

57       Automobile & Truck Maintenance                                                                                                                                                                        $                 -

58       Telephone                                                                                                                                                                                             $                 -

59       Postage                                                                                                                                                                                               $                 -

60       Dues & Subscriptions                                                                                                                                                                                  $                 -

61       Legal & Accounting                                                                                                                                                                                    $                 -

62       Interest - Automobile                                                                                                                                                                                 $                 -

63       Interest - Mortgage                                                                                                                                                                                   $                 -

64       Interest - Fixed Assets                                                                                                                                                                               $                 -

65       Interest - Operating                                                                                                                                                                                  $                 -

66       Audit                                                                                                                                                                                                 $                 -

67       Rent - Automotive/Equipment                                                                                                                                                                           $                 -

68       Rent - Office                                                                                                                                                                                         $                 -

69       Real Estate Taxes                                                                                                                                                                                     $                 -

70       Data Processing                                                                                                                                                                                       $                 -
         DMA Rate Setting
         Updated: September 28, 2007                                                                                                                                                  bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                 Page 11 of 15                                                                Sched C-1 Medicaid HRI-R Codes
                                                                                                                                  NC Department of Health and Human Services
                                                                                                                                           Division of Medical Assistance

                                                                                                                 2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID:            0                                                           Mental              Foster Care           Therapeutic             BHLTR                   BHLTR               BHLTR               BHLTR
Corporate Name     0                                                          Health Svc           Therapeutic           Behavioral             4 Beds or               5 Beds or           4 Beds or           5 Beds or                             OTHER
Audit Date:        1/0/1900                                                                           Child               Services                Less                    More                Less                More                                CAP MR,
                                                                               LEVEL l              LEVEL ll              LEVEL ll              LEVEL lll               LEVEL lll           LEVEL lV            LEVEL lV            PRTF            ICF MR, etc.
                                                                                H0046                S5145                 H2020                  H0019                   H0019               H0019               H0019                                                       TOTAL

                                                                                  1                     2                     3                      4                      5                   6                   7                8                    9                     10

71       Travel & Entertainment                                                                                                                                                                                                                                         $                 -

72       Licenses for individuals                                                                                                                                                                                                                                       $                 -

73       Licenses for facility                                                                                                                                                                                                                                          $                 -

74       Bloodborne Pathogen (OSHA) for Non-Medicaid FTE's                                                                                                                                                                                                              $                 -

75       Employee Criminal Records Check Fees for Non- Medicaid FTE's                                                                                                                                                                                                   $                 -

76       Management Services                                                                                                                                                                                                                                            $                 -

77       Advertising                                                                                                                                                                                                                                                    $                 -

78       Printing                                                                                                                                                                                                                                                       $                 -
         Meetings/Seminars/Training (Include Operations Personnel Costs
79       to set up)                                                                                                                                                                                                                                                     $                 -

80       Miscellaneous                                                                                                                                                                                                                                                  $                 -

81       Salaries and Other Expenses including Admin.                                                                                                                                                                                                                   $                 -
82       TOTAL OTHER COSTS                                                                                                                                                                                                      $          -    $                   -   $                 -

83               TOTAL EXPENSES BEFORE DEPRECIATION                       $                -   $             -       $               -      $               -       $               -   $               -   $               -   $          -    $                   -   $                 -
DEPRECIATION

84       Depreciation - Building & Improvement - Office                                                                                                                                                                                                                 $                 -

85       Depreciation - Automotive                                                                                                                                                                                                                                      $                 -

86       Depreciation - Equipment                                                                                                                                                                                                                                       $                 -

87       TOTAL DEPRECIATION                                               $                -   $                 -   $                 -    $                -      $               -   $               -   $               -   $          -    $                   -   $                 -


88       TOTAL RATE SETTING EXPENSES                                      $                -   $                 -   $                 -    $                -      $               -   $               -   $               -   $          -    $                   -   $                 -

NON-ALLOWABLE EXPENSES

89       Child Development                                                                                                                                                                                                                                              $                 -

90       Other Child and Family Services                                                                                                                                                                                                                                $                 -

91       Higher Education                                                                                                                                                                                                                                               $                 -

92       Bad Debts                                                                                                                                                                                                                                                      $                 -

93       Multi-Purpose Group Home                                                                                                                                                                                                                                       $                 -

94       Miscellaneous &Non-Allowable costs - Medicaid                                                                                                                                                                                                                  $                 -

95       In Kind Donations / Contributions                                                                                                                                                                                                                              $                 -

96       Penalties                                                                                                                                                                                                                                                      $                 -

         DMA Rate Setting
         Updated: September 28, 2007                                                                                                                                                                                                           bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                                                    Page 12 of 15                                                                                      Sched C-1 Medicaid HRI-R Codes
                                                                                                                      NC Department of Health and Human Services
                                                                                                                                Division of Medical Assistance

                                                                                                    2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID:          0                                                Mental              Foster Care            Therapeutic              BHLTR                   BHLTR               BHLTR               BHLTR
Corporate Name   0                                               Health Svc           Therapeutic            Behavioral              4 Beds or               5 Beds or           4 Beds or           5 Beds or                             OTHER
Audit Date:      1/0/1900                                                                Child                Services                 Less                    More                Less                More                                CAP MR,
                                                                  LEVEL l              LEVEL ll               LEVEL ll               LEVEL lll               LEVEL lll           LEVEL lV            LEVEL lV            PRTF            ICF MR, etc.
                                                                   H0046                S5145                  H2020                   H0019                   H0019               H0019               H0019                                                       TOTAL

                                                                     1                     2                      3                       4                      5                   6                   7                8                    9                     10

97       Extraordinary Items                                                                                                                                                                                                                                 $                 -

98       TOTAL NON-ALLOWABLE EXPENSES                                                                                                                                                                                                                        $                 -

99           TOTAL TO MATCH AUDIT (Line 88 plus line 98)     $                -   $                  -   $                  -    $                   -   $               -   $               -   $               -   $          -    $                   -   $                 -

100      TOTAL RESIDENT DAYS PROVIDED                        $                -   $                  -   $                  -    $                   -   $               -   $               -   $               -   $          -    $                   -   $                 -

101      Total Allowable Expenses by Definition of Service   $                -   $                  -   $                  -    $                   -   $               -   $               -   $               -   $          -    $                   -   $                 -




         DMA Rate Setting
         Updated: September 28, 2007                                                                                                                                                                                                bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                                         Page 13 of 15                                                                                      Sched C-1 Medicaid HRI-R Codes
                                                           NC Department of Health and Human Services
                                                                 Division of Medical Assistance




                                     2008 MENTAL HEALTH RESIDENTIAL TREATMENT COST REPORT

   Federal Tax ID #: 0
   Corporate Name:                       0

  SCHEDULE C-2                                  POSITION / FTE's by Level of Care
                          LIST THE JOB TITLE, LEVEL OF STAFF AND THE NUMBER OF FTEs ASSOCIATED WITH THE JOB TITLE

                                                     MEDICAID TREATMENT EXPENSES
                                                                       Mental      Therape                                       5 Beds
                                                                        Health       utic   Group 4 Beds or 5 Beds       4 Beds or More
                                                                       Service      Foster  Homes    Less      or More or Less LEVEL
                                                                       LEVEL I       Care  LEVEL II LEVEL III LEVEL III LEVEL IV   IV
                   JOB TITLE                  Staff Qualification       H0046       S5145   H2020    H0019      H0019    H0019   H0019 TOTALS
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                                                                                                                    -
                                                         Total FTEs:          -          -              -   -    -           -          -           -
                                             FTEs from Schedule C-1:          -          -              -   -    -           -          -           -


DMA Rate Setting
Updated: September 28, 2007                                                 14 of 15                              bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
                                                                                                                                Schedule C-2 FTE Summary
                                                       NC Department of Health and Human Services
                                                             Division of Medical Assistance

                                             2008 Mental Health Residential Treatment Cost Report
SCHEDULE D                    RELATED PARTY TRANSACTIONS
Corporate Name:                        0
Tax ID:                                  0
                                                                                                                                 Number of
  Description of Line Item        Line          Program/Cost                                                      Expense        Paid Hours
     (Expense/Cost)                 #        Center/Column Name     Name of Related Party       Relationship      Amount           (If Applicable)




ROUND FUNDS TO THE NEAREST WHOLE DOLLAR.
DMA Rate Setting                                                                                               bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Updated: September 28, 2007                                             15 of 15                                         Schedule D-Related Party Trans

				
DOCUMENT INFO
Description: 2008 Federal Tax Sched document sample