Equipment Sales Contract by zyx17711

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									          2009 Texas                                                                                                                   9-Digit Contract #
                                                                    SCHEDULE B
          Cost Report

                                                      RELATED PARTY TRANSACTIONS
SECTION 1A
    PURCHASES AND LEASES FROM A RELATED PARTY
     l Complete Section 1A if supplies or nondepreciable equipment were purchased or leased from a related party.
     l Complete Sections 1A, 3A and 3B if buildings/facilities were leased from a related party and ATTACH A COPY OF THE SIGNED RELATED PARTY LEASE.
     l Complete Sections 1A and 3C if vehicles were leased from a related party.
     l Complete Sections 1A and 4 if building/facilities or other depreciable items were purchased from a related party and ATTACH A COPY OF THE
       RELATED PARTY SALES CONTRACT.
     l Complete Section 1A if services were purchased from related organizations. (For related individuals, see Section 1B).
                       A                             B                 C                             D                             E                  F
                    Name of                     Percentage        Cost Report                 Description of                    Cost to            Cost to
                    Related                         of               Line                  Purchased or Leased                 Provider        Related Party /
              Party / Organization              Ownership          Number                  Items/Goods/Services                                 Organization




SECTION 1B
    SERVICES PURCHASED FROM RELATED INDIVIDUALS
     l Complete Section 1B if services were purchased from a related individual who IS NOT an employee of the provider/facility, any of its controlling
       entities, parent company/sole member, or any of the entities owned or managed by the related party management company.
     l Do not complete Section 1B, but complete Schedule C if the related individual IS an employee of the provider/facility, any of its controlling entities,
       parent company/sole member, or any of the entities owned or managed by the related party management company.
                       A                             B                 C                             D                             E                  F
                   Name of                      Percentage        Cost Report                  Description of                Total Hours           Total
                 Related-Party                      of               Line                         Service                     Worked In         Compensation
                  Individual                    Ownership          Number                       Performed                    The Program          Earned




                                                                    Schedule B - Page 1
       2009 Texas                              SCHEDULE B                                   9-Digit Contract #
       Cost Report                             (CONTINUED)
                                     RELATED PARTY TRANSACTIONS
SECTION 2A
    RELATED PARTY LOANS FROM ORGANIZATIONS OR GROUPS OF INDIVIDUALS (i.e., lending services)
                A                    B            C                     D               E               F
              Name of            Percentage   Cost Report          Description of     Cost to       Allowable
              Related                of          Line            Goods or Services   Provider      Related Party
               Party             Ownership     Number           Paid For With Loan                 Interest Cost




SECTION 2B
    RELATED PARTY LOAN FROM AN INDIVIDUAL (i.e., lending services)
                A                    B            C                     D               E               F
              Name of            Percentage   Cost Report          Description of     Cost to       Allowable
              Related                of          Line            Goods or Services   Provider      Related Party
               Party             Ownership     Number           Paid For With Loan                 Interest Cost




                                                Schedule B - Page 2
               2009 Texas                                                                               SCHEDULE B                                                                                       9-Digit Contract #
               Cost Report                                                                               (continued)
                                                                               RELATED PARTY TRANSACTIONS
SECTION 3A
COST OF BUILDING LEASE TO RELATED PARTY
                        A                                             B                     C                       D                           E                           F                          G                           H
                 Description                                   Month/Year              Years of                Historical                   Salvage                 Depreciation               Prior Period                   Depreciation
                  of Asset                                      Placed in               Useful                   Cost                        Value                     Basis                   Accumulated                   For Reporting
                                                                 Service                 Life                                                                       (D minus E)                Depreciation                     Period

1. BUILDINGS:                                                                      <--Attachment #


                                                                                                                                    1. Total Building Depreciation . . . . . . . . . . . . (to item 4 below) . . . . . .                     .00
2. BUILDING EQUIPMENT:                                                             <--Attachment #



                                                                                                                                    2. Total Building Equipment Depreciation: . . (to item 4 below) . . . . . .                              .00
3. OTHER DEPRECIATION:                                                             <--Attachment #



                                                                                                                                    3. Total Other Depreciation: . . . . . . . . . . . . . . (to item 4 below) . . . . .                     .00


     4.                                                                                                                                                                                       . .
           Total Depreciation Expense (from items 1 thru 3 above) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.. $ . . . . . . . . . . . . . .              .00

     5.                                                                                                                                                                                                          . .
           Mortgage Interest Expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5..$ . . . . . . . . . . .   .00

     6.                                                         . ...... . ..... .. .......
           SUBTOTAL (sum items 4 and 5) . . . . . . . . . . . .To. Schedule. B,. Section. 1A,. Column F.and Lease/Rental - Building/Facility . . . . . . . . . . . . . . . 6.. $. . . . . .
                                                                                                                                                                           . .                                                               .00

     7.                                                                     . . Schedule B, . . . . . 1A, Column
           Other Interest Expense . . . . . . . . . . . . . . . . . . . . . To . . . . . . . . . .Section . . . . . . . . F and Interest - Other Facility/Operations Notes . . . . . . . .7. .$ . . . . . . . . . . . . .
                                                                                                                                                                                           . .                                               .00

     8.                                                                . ...... ....... .. .....
           Ad Valorem Property Taxes . . . . . . . . . . . . . . . . .To. Schedule. B, Section. 1A,. Column F and Tax - Ad Valorem Real Estate . . . . . . . . . . . . . . . . .8..$ . . . .
                                                                                                                                                                                 . .                                                         .00

     9.                                                                       .. ...... . ..... .. .....
           Property Insurance . . . . . . . . . . . . . . . . . . . . . . . . To .Schedule .B, .Section .1A, .Column F and Insurance - Building, Contents and Grounds . . . . . .9. .$ . . . . . . . . . . . . . . .
                                                                                                                                                                                  . .                                                        .00

                                                                  .. ...... . ..... .. .....
     10. Other Expense (Describe below) . . . . . . . . . . . . . To .Schedule .B, .Section .1A, .Column F and Other Building/Facility/Operations Expenses . . . .10.. $ . . . . . . . . . . . . . . . .
                                                                                                                                                                   .. .                                                                      .00




                                                                                                                                                                           ..
     11. TOTAL Cost of Building Lease to Related Party (sum items 6 thru 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11. .$. . .                                                        .00


ATTACH A COPY OF RELATED PARTY LEASE                                                                                                <--Attachment #

                                                                                                     Schedule B - Page 3
             2009 Texas                                                                                  SCHEDULE B                                                                                         9-Digit Contract #
             Cost Report                                                                                  (continued)

                                                                               RELATED PARTY TRANSACTIONS

SECTION 3B
COST OF DEPARTMENTAL EQUIPMENT LEASE TO RELATED PARTY
                      A                                               B                     C                        D                            E                            F                           G                    H
               Description                                    Month/Year               Years of                 Historical                    Salvage                 Depreciation                 Prior Period               Depreciation
                of Asset                                       Placed in                Useful                    Cost                         Value                     Basis                     Accumulated               For Reporting
                                                                Service                  Life                                                                         (D minus E)                  Depreciation                 Period

1. DEPARTMENTAL EQUIPMENT                                                          <--Attachment #




                                                                                                                                     1. Total Departmental Equipment Depreciation (to item 2 below) . . . . . .                              .00

    2.                                               ....
         Total Departmental Equipment Depreciation Expense. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2.$                                             .00
    3.      .... ......
         Interest .Expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.$                   .00
    4.                             ....
         Other Expense (Describe below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4.$                               .00



    5.   TOTAL Cost of Departmental Equipment Lease to Related Party (sum items 2 thru 4)
         To Sch. B, Sect. 1A, Col. F and Lease Rental - Departmental Equipment). . . . . . . . . . . . . . . . . . . . . . . . . . . .............. . . . . . . . . . . . . 5.$                                                              .00


ATTACH A COPY OF RELATED PARTY LEASE                                                                                                 <--Attachment #

                                                                                                      Schedule B - Page 4
              2009 Texas                                                                                 SCHEDULE B                                                                                         9-Digit Contract #
              Cost Report                                                                                 (continued)
                                                                                RELATED PARTY TRANSACTIONS

SECTION 3C
COST OF TRANSPORTATION EQUIPMENT LEASE TO RELATED PARTY
                       A                                              B                      C                        D                           E                            F                           G                    H
                Description                                    Month/Year               Years of                Historical                    Salvage                  Depreciation                Prior Period               Depreciation
                 of Asset                                       Placed in                Useful                   Cost                         Value                      Basis                    Accumulated               For Reporting
                                                                 Service                  Life                                                                         (D minus E)                 Depreciation                 Period

1. TRANSPORTATION EQUIPMENT                                                        <--Attachment #




                                                                                                                                      1. Total Transportation Equipment Depreciation . . . (to item 2 below) . . . . . .                     .00

     2.                                                .....
          Total Transportation Equipment Depreciation Expense. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2.$                                            .00
     3.              .....
          Interest Expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.$                   .00
     4.             .......
          Insurance Expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4.$                     .00
     5.                             ....
          Other Expense (Describe below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5.$                              .00



     6.   TOTAL Cost of Transportation Equipment Lease to Related Party (sum items 2 thru 5)
          To Sch. B, Sect. 1A, Col. F and Lease Rental - Transportation Equipment). . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. .. .. .. . . . . . . . . . . . 5.$                                                      .00


ATTACH A COPY OF RELATED PARTY LEASE                                                                                                  <--Attachment #

                                                                                                      Schedule B - Page 5
           2009 Texas                                     SCHEDULE B                                                                                   9-Digit Contract #
           Cost Report                                     (continued)
                                        RELATED PARTY TRANSACTIONS
SECTION 4
RELATED PARTY PURCHASES - DEPRECIATION AND AMORTIZATION - (Straight-Line Method Only)
                A                  B             C                D                     E                              F                             G                             H
            Description        Month/Year     Years of        Historical           Salvage                    Depreciation                  Prior Period                      Depreciation
             of Asset           Placed in      Useful           Cost                Value                        Basis                      Accumulated                      For Reporting
                                 Service        Life                                                          (D minus E)                   Depreciation                        Period

1. BUILDINGS:                               <--Attachment #




                                                                           1. Transfer Total to Depreciation - Buildings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   .00
2. BUILDING FIXED EQUIPMENT:                <--Attachment #




                                                                           2. Transfer Total to Depreciation - Building Fixed Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . .00 . . . . .
                                                                                                                                                                                            ...
3. LAND IMPROVEMENTS:                       <--Attachment #




                                                                           3. Transfer Total to Depreciation - Land Improvements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       .00
4. LEASEHOLD IMPROVEMENTS:                  <--Attachment #




                                                                           4. Transfer Total to Amortization - Leasehold Improvements . . . . . . . . . . . . . . . . . . .                        .00
5. DEPARTMENTAL EQUIPMENT:                  <--Attachment #




                                                                           5. Transfer Total to Depreciation/Amortization - Facility Other . . . . . . . . . . . . . . . . . . . . . . . . . .00 . .
                                                                                                                                                                                             ...



ATTACH A COPY OF RELATED PARTY FACILITY/BUILDING SALES CONTRACT                                                                                                       <--Attachment #

                                                         Schedule B - Page 6
           2009 Texas                                       SCHEDULE B                                                                                  9-Digit Contract #
           Cost Report                                       (continued)
                                          RELATED PARTY TRANSACTIONS
SECTION 4 (continued)
RELATED PARTY PURCHASES - DEPRECIATION AND AMORTIZATION - (Straight-Line Method Only)
                A                    B             C                D                     E                             F                             G                              H
            Description          Month/Year     Years of        Historical           Salvage                   Depreciation                  Prior Period                      Depreciation
             of Asset             Placed in      Useful           Cost                Value                       Basis                      Accumulated                      For Reporting
                                   Service        Life                                                         (D minus E)                   Depreciation                        Period


6. TRANSPORTATION EQUIPMENT:                  <--Attachment #




                                                                             6. Transfer Total to Depreciation - Transportation Equipment . . . . . . . . . . . . .                           .00
7. OTHER AMORTIZATION:                        <--Attachment #




                                                                             7. Transfer Total to Amortization - Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .            .00
8.CENTRAL OFFICE DEPRECIATION:                <--Attachment #




                                                                             8. Transfer Total to Central Office Depreciation . . . . . . . . . . . . . . . . . . . . . . .                   .00



                                                           Schedule B - Page 7

								
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