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									                                SFY 2008 Request for Revision Report
                                Nursing Facility Direct Care Staff Enhancement
                                (For the reporting period of September 1, 2006 to April 30, 2007)
FACILITY IDENTIFICATION                                               (type or print in ink)                 9-Digit NF Contract #:
Facility Name:


Street Address (street, city, state, 9-digit zip):


Mailing Address (street or P.O. Box, city, state, 9-digit zip):


Phone Number:                                              FAX Number:                             E-Mail:



CONTRACTING ENTITY
Name of Contracting Entity (Corporation Name, Partnership Name, etc.):


Mailing Address (street or P.O. Box, city, state, 9-digit zip):


Phone Number:                                              FAX Number:                             E-Mail:



CONTACT
Employee To Contact About This Report:                     Employee's Title:                       Business Name:


Contact's Mailing Address (street or P.O. Box, city, state, 9-digit zip):


Phone Number:                                              FAX Number:                             E-Mail:



PREPARER
Name of Person Who Prepared This Report:                   Title:                                  Business Name:


Preparer's Mailing Address (street or P.O. Box, city, state, 9-digit zip):


Phone Number:                                              FAX Number:                             E-Mail:



RECORDS LOCATION
Records for audit of this report are located at (street, city, state, 9-digit zip):



HHSC CONTACTS                                                         MAILING ADDRESS
For completion information                                            Mail completed report to:                     Special Mail Delivery:
                            .... ..
     Pam McDonald . . . . .(512) .491-1373                            HHSC Rate Analysis                            HHSC Rate Analysis, MC H-400
                                                                      Mail Code H-400                               Braker Center, Building H
For mailing & receipt information                                     P.O. Box 85200                                11209 Metric Blvd.
     (512) 491-1354                                                   Austin, Texas 78708-5200                      Austin, Texas 78758-4021

                                HEALTH AND HUMAN SERVICES COMMISSION USE ONLY
                 Original Receipt Date                                        Other Receipt Date                               Verification
                                                                                                             Pre-Edit       Date
                                                                                                                            Initials
                                                                                                             Edit           Date
                                                                                                                            Initials
                                                                                                             Audit          Date
                                                                                                                            Initials
                          2008                                                                                                                9-Digit NF Contract #
                                                                           GENERAL INFORMATION
      Request for Revision Report

1.    Current DADS NF 9-digit Contract Number . . . . . . . . . . . . . . . . . . . . . . . 1.. . . . . . . . . . . . . . . .
                                                                                            .
2.    9-digit Contract Number prior to any Successor Liability Agreement                    2.
3.    DADS NF 4-digit Provider Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. . . . . . .
                                                                                                                                      ..
4.    Texas County Code in Which Accounting Records are Located ("999" if outside Texas) . . . . . . . . . . 4.. . . . . . . . . . . . . . . . . . . .
                                                                                                                                             .
                                                                                                                                   Month                  Day             Year
5.                                                                                                                                     0 .
      Reporting Period - Beginning Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. . . 9 . . . . . . . . . . 1. . .
                                                                                                          5. .           .                                               0     6
6.    Reporting Period - Ending Date . . . . . . . . . . . . . . . . . . . . . . . . . . . .                               6.     0       4             3      0         0     7
                                                                                                                                                              0. No          1. Yes
7.    Were any owner-employees or other related-party employees included on this report?
      If YES, complete Schedule C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.
                                                                                                                                                              0. No          1. Yes
8.    Were any contracted services included on this report provided by a related organization?
      If YES, complete Schedule B, Section 1A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.
                                                                                                                                                              0. No          1. Yes
9.    Were any contracted services included on this report provided by a related individual?
      If YES, complete Schedule B, Section 1B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.

10. Number of facility beds LICENSED for NURSING care by DADS at the end of your
                                                                                                                                                  ..
    reporting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.. . . .
                                                                                                                                                              0. No          1. Yes
11. Were the number of beds reported in item 10 licensed for the entire reporting period?
                                                                                                                                          ..
    If NO, complete Schedule I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.. . . .

12. Number of LICENSED NURSING beds CONTRACTED for Medicaid nursing care by DADS
                                                                                                                                         ..
    at the end of your reporting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12. .
                                                                                                                                                              0. No          1. Yes
13. Were the number of beds reported in item 12 contracted for the entire reporting period?
                                                                                                                                          ..
    If NO, complete Schedule I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.. . .

14. The only nurse aides to be included on this report are Certified Nurse Aides and nurse
      aides in training who have completed at least the first 16 hours of a Nurse Aide Training
      and Competency Evaluation Program (NATCEP). Have you excluded all time worked                                                                     0. No                1. Yes
      before sixteen hours of training are completed as well as associated salaries and wages
      from this report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.. . . . .
                                                                                                                                                    ..
                                                                                                                                                              0. No          1. Yes

15. Does this facility provide an in-house NATCEP?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15. . . . . . .
                                                                                                                              ..

16. Does the contracting entity hold any other Nursing Facility contracts with the State of
      Texas? If yes, report the total number of contracts (including this contract) and list the
      9-digit contract number for each. (Attach additional sheet(s) if necessary.) . . . . . . . . . . . . . . . . 16.. . . . . . . . . . . . . . . . . . . . . . .
                                                                                                                   ..
       9-digit contract #                    9-digit contract #                      9-digit contract #                   9-digit contract #                   9-digit contract #



                                                                                                                                                              0. No          1. Yes
17. Have you attached to this report copies of the required Mandatory Cost Report
                                                                                                                           ..
    Training Certificate(s) for each preparer signing this report? . . . . . . . . . . . . . . . . . . . . . . . . . . . .17.. . . . . . . . . . . . . . . . . . . . . . .
      (Attachment #                     ).                                                                     Items 18 & 19 are reserved for future use.
                                                         Page 2
                                  1. Yes



                                  1. Yes



                                  1. Yes




                                  1. Yes




                                  1. Yes




                                  1. Yes



                                  1. Yes




                                  1. Yes



Items 18 & 19 are reserved for future use.
                       2008                                      DAYS OF SERVICE IN MEDICAID-                         9-Digit NF Contract #
  Request for Revision Report                                   CONTRACTED BEDS (no decimals)




            TILE                                Medicaid Days               Medicaid                  Medicaid
                                            (Excluding Star+Plus                                                                           TOTAL
            Group                                & Hospice)
                                                                          Hospice Days             Star+Plus Days


                                   ..
       201 . . . . . . . . . . . . 20.. . . . . . . . .             21.                      22.                             23.
                                   ..
       202 . . . . . . . . . . . . 24.. . . . . . .                 25.                      26.                             27.
                                   ..
       203 . . . . . . . . . . . . 28.. . . . . . . . . .           29.                      30.                             31.
                                   ..
       204 . . . . . . . . . . . . 32.. . . . . . .                 33.                      34.                             35.
                                   ..
       205 . . . . . . . . . . . . 36.. . . . . . . . . .           37.                      38.                             39.
                                   ..
       206 . . . . . . . . . . . . 40.. . . . . . .                 41.                      42.                             43.
                                   ..
       207 . . . . . . . . . . . . 44.. . . . . . . . .             45.                      46.                             47.
                                   ..
       208 . . . . . . . . . . . . 48.. . . . . . . . .             49.                      50.                             51.
                                   ..
       209 . . . . . . . . . . . . 52.. . . . . . . . . . .         53.                      54.                             55.
                                   ..
       210 . . . . . . . . . . . . 56.. . . . . . . . . . .         57.                      58.                             59.
                                   ..
       211 . . . . . . . . . . . . 60.. . . . . . . . . . .         61.                      62.                             63.
                                   ..
       212 . . . . . . . . . . . . 64.. . . . . . . . . . . .       65.                      66.                             67.

                              ..
       TOTALS . . . . . . . . 68.. . . . . . .                      69.                      70.                             71.

                                                                                                                         ..
72. Medicare days of service in Medicaid-contracted beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72. . . . . . .
                                                                                                                            ..
73. Other days of service in Medicaid-contracted beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73. . . . . .

                                                                                                              ..
74. Total days of service in Medicaid-contracted beds (Sum items 71 thru 73). . . . . . . . . . . . . . . . . 74.. . . . . . . . . . . . . . . . . . . . .


                         DAYS OF SERVICE IN NON-MEDICAID-CONTRACTED BEDS (include no decimals)

                                                                                                                           ...
75. Days of service in non-Medicaid-contracted beds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75. . . . . .


                                                                                                                76.
76. TOTAL DAYS OF SERVICE (Sum items 74 and 75) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

For Medicaid days of service identified in items 20 thru 71, enter the days of service qualifying for supplemental payments for ventilator
or pediatric tracheostomy care.

      Supplemental                              Medicaid Days               Medicaid                  Medicaid
                                            (Excluding Star+Plus                                                                           TOTAL
      Payment Type                               & Hospice)
                                                                          Hospice Days             Star+Plus Days


Vent. Continuous . . . . . . . 77. . . . . .
                               ...                                  78.                      79.                             80.
                                    81.
Vent. Partial . . . . . . . . . . . . . . . .                       82.                      83.                             84.
Pediatric Tracheostomy . . 85. . . . . . . . .
                           ...                                      86.                      87.                             88.



                                                                           Page 3
                     2008                                                                                                                        9-Digit NF Contract #
                                                      DIRECT CARE HOURS AND COMPENSATION
  Request for Revision Report



                                   Report hours/costs for MEDICAID-CONTRACTED BEDS ONLY

100. Were any expenses reported on this page the result of the allocation of expenses?                           0. No                                                    1. Yes
     If YES, attach a detailed allocation summary (Attachment # _____________). . . . . . . . . . . . . . . 100.. . . .
                                                                                                            ...


        EMPLOYEES                                                                                                 Paid Hours                                 Salaries & Wages
                                                                                                                                 no
        Registered Nurses (including RN DONs) . . . . . . . . . . . . . . . . . . 101.. hrs. . . . . . . . . . . . . decimals . . . . 102.. $
                                                                                  ... ...                             ....            ... .                                          .00
                                                                                                                                 no
        Licensed Vocational Nurses (including LVN DONs) . . . . . . . . . .103. . hrs. . . . . . . . . . . . . . . . . . . . .104. $
                                                                            ... ...                                            ...
                                                                                                                                 decimals                                            .00
                                                                                                                                 no
        Medication Aides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105.. hrs. . . . . . . . . . . . . . . .
                                                                                               ... ...                           decimals       106. $                               .00
                                                                                                                                 no
        Certified Nurse Aides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107. .hrs. . . . . . . . . . .
                                                                                              ... ...                            decimals       108. $                               .00

        CONTRACT LABOR                                                                                            Paid Hours                                    Compensation
                                                                                                                                 no
        Contract - Registered Nurses (including RN DONs) . . . . . . . . . .109. .hrs. . . . . . . . . . . . . . . . . . . . .110. .$. . . . . . . . .
                                                                             ... ...                         decimals          ...                                                   .00
                                                                                                                                 no
        Contract - Licensed Vocational Nurses (including LVN DONs) . . . 111.. hrs.. . . . . . . . . . . . . . . . . . . . 112.. $ . . . . .
                                                                         ... ...                                           ... . decimals                                            .00
                                                                                                                                 no
        Contract - Medication Aides . . . . . . . . . . . . . . . . . . . . . . . . . . .113. .hrs. . . . . . . . . . . . . . . . . . . . .114. $
                                                                                          ... ...                                decimals   ...                                      .00
                                                                                                                                 no
        Contract - Certified Nurse Aides . . . . . . . . . . . . . . . . . . . . . . . 115. . . . . . . . . . . . . . . . . . . . . . . 116. $
                                                                                       . . . . hrs.                              decimals                                            .00

117. Payroll Taxes - FICA and Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117. . $ . . . . . . . . . . . . . .
                                                                                                                                       ... .                                         .00
                                                                                                                                                       0. No              1. Yes
118. Does item 117 equal 7.65% of the sum of items 102, 104, 106, and 108? (If NO, provide explanation.) . . . . .118. . . . . .
                                                                                                                  ....




119. Payroll Taxes - State and Federal Unemployment. . . . . .(if . . . . . provide.explanation .below).... .. .. . .119... ..... .. .. . . . . . . . . . . . .
                                                                . none, . . . . . . . . . . . . . . . . .            . . .. $
                                                                                                                       .                                                             .00



120. Workers' Compensation - Insurance Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.. $ . . . .
                                                                                                                            ... .                                                    .00
121. Workers' Compensation - Paid Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.. $ . . .
                                                                                                                                   ... .                                             .00
122. Employee Benefits - Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122. .$. . .
                                                                                                                                      ...                                            .00
123. Employee Benefits - Life Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123.. $ . .
                                                                                                                                        ... .                                        .00
124. Employee Benefits - Other Benefits . . . . . . . . . . . . . . . . (describe below). .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..124...$ . . . .
                                                                        .............                                                          .. .. .. .                            .00



125. TOTAL DIRECT CARE COSTS                                                                        (sum
     items 102, 104, 106, 108, 110, 112, 114, 116, 117 and 119 thru 124) . . . . . . . . . . . . . . . . . .                                    125. $                               .00

                                                                                                                                            Items 126 thru 149 are reserved for future use.




                                                                                       Page 4
             2008                                                                                                             9-Digit NF Contract #
                                                            SCHEDULE B
 Request for Revision Report
SCHEDULE A is reserved for future use.
                                                   RELATED-PARTY TRANSACTIONS
SECTION 1A
       PURCHASES AND LEASES FROM A RELATED PARTY
       -   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         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
       -   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.
       -   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         Report                   Description of                 Total Hours       Total
                  Related-Party                    of              Line                       Service                      Worked In    Compensation
                   Individual                  Ownership          Number                    Performed                    The Program       Earned

                                                                                                                                        $
                                                                                                                                        $
                                                                                                                                        $
                                                                                                                                        $


                                                                           Page 5
               2008                                                                                          9-Digit NF Contract #
                                                      SCHEDULE C
  Request for Revision Report

                                                   RELATED-PARTY
     COMPENSATION OF OWNER-EMPLOYEES AND OTHER RELATED-PARTY EMPLOYEES

                        FOR EACH OWNER-EMPLOYEE AND/OR RELATED-PARTY EMPLOYEE
                                           PROVIDING DIRECT CARE SERVICES
     -   Complete a separate Schedule C - Parts 1 and 2.
     -   Attach an organizational chart which indicates the employee's position and name.
               PART 1: COMPENSATION                                      PART 2: ALLOCATION OF COMPENSATION
1. Name:                                                            11. Provide a breakdown of how the total compensation
                                                                        reported in item 8 was allocated.
2. Title:                                                                Business Component                         Amount

3. Type of Position:
                                                                                                         $                      .00
4. Location of Position within Organizational Structure:
         Facility      Contracting       A Controlling                                                   $
                                                                                                         $                      .00
                       Entity            Entity
            Parent Company/Sole Member/Related-Party                                                     $                      .00
            Management Company
5. Description of Duties (must be direct care):                                                          $                      .00

                                                                                                         $                      .00

                                                                                                         $                      .00
6. Relationship to Provider:
                                                                                                         $                      .00

7. Percentage of Ownership (If no ownership, enter "None"):         11. Total Compensation
                                                                        (must be equal to item 8) . . $. . . .
                                                                                                      .                         .00

                                                                  12. What % of total compensation
8. Total Compensation                                                 reported in item 8 was
   for Direct Care:             $                             .00     allocated to this report? . . . . . . . . . .             %

9. What total number of hours was                                  13. What % of total hours reported
   worked to earn the total                                            in item 9 were allocated
   compensation in item 8?                                    hrs.     to this report? . . . . . . . . . . .                    %

10. Describe method used to allocate the total compensation         14. Identify the report line numbers on which the
    shown in item 8. Provide detail of allocation in                    salary allocated to this report is reported.
    Part 2, Items 11 and 14:
                                                                        Line #                      Amount      $
                                                                        Line #                      Amount      $
                                                                        Line #                      Amount      $
                                                                        Line #                      Amount      $
                                                                        Line #                      Amount      $


ATTACH AN ORGANIZATIONAL CHART                                Attachment #
                                                           Page 6
                      2008                                                                                                           9-Digit NF Contract #
                                                                           SCHEDULE I
     Request for Revision Report

SCHEDULES D, E, F, G & H, are reserved for future use.

                              Bed Additions and Deletions During the Reporting Period

Attach documentation (e.g., letter from DADS) to support each change in number of beds that
occurred during the reporting period.

LICENSED BEDS
Number of facility beds LICENSED for NURSING care at the beginning of
your reporting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

                                               month      day      year          New # of Lic. Beds                       Attachment #

    Change # 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of facility beds LICENSED for NURSING care at the end of your
reporting period (must equal amount reported in item 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


CONTRACTED BEDS
Number of licensed nursing beds CONTRACTED for Medicaid nursing care
at the beginning of your reporting period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

                                               month      day      year          New # of Cont. Beds                       Attachment #

    Change # 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

    Change # 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Number of licensed nursing beds CONTRACTED for Medicaid nursing care at
the end of your reporting period (must equal amount reported in item 12). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



                                                                             Page 7
                     2008                                                                                        9-Digit NF Contract #
                                                       REPORT CERTIFICATION
     Request for Revision Report

 AS SIGNER OF THIS REPORT, I HEREBY CERTIFY THAT:
     -      I have read the note below, the cover letter and all the instructions applicable to this report.
     -      I have read the Cost Determination Process rules and Enhanced Direct Care Staff Rate rules applicable
            to this report, which define allowable and unallowable costs and provide guidance in proper reporting.
     -      I have reviewed this report after its preparation.
     -      To the best of my knowledge and belief, this report is true, correct and complete, and was
            prepared in accordance with the Cost Determination Process rules, Enhanced Direct Care Staff Rate rules,
             and all the instructions applicable to this report.
     -      This report was prepared from the books and records of the contracted provider and/or its controlling entity.

 NOTE:
            This REPORT CERTIFICATION must be signed by an individual legally responsible for the conduct of the facility or
            legally authorized to bind the facility, such as the sole proprietor, a partner, a corporate officer, an association officer,
            a governmental official, a limited liability company member, a person authorized by the applicable DADS Form 2031
            for the interested party on file at the time of the request, or a legal representative for the interested party. The
            administrator is authorized to sign only if he/she holds one of these positions. Misrepresentation or falsification of any
            information contained in this report may be punishable by fine and/or imprisonment.


SIGNER IDENTIFICATION
Name of Contracted Provider


Printed/Typed Name of Signer                                   Title of Signer


Address of Signer (street or P.O. Box, city, state, 9-digit zip):


Phone Number (including area code)                             FAX Number (including area code)




                 SIGNATURE OF SIGNER                                                                      DATE


SIGNER AUTHORITY:                          Sole Proprietor                              Association Officer
     (check one)                           Partner                                      Governmental Official
                                           Corporate Officer                            L. L. C. Member


Subscribed and sworn before me, ___________________________________________, a Notary Public,
on the __________________day of __________________________________________, _________.


                                                                                     NOTARY SIGNATURE


                     NOTARY SEAL
                                                                                    COMMISSION EXPIRES



                                                                                  NOTARY PUBLIC, STATE OF




                                                                       Page 8
              2008                         METHODOLOGY                                    9-Digit NF Contract #
 Request for Revision Report               CERTIFICATION

 AS PREPARER OF THIS REPORT, I HEREBY CERTIFY THAT:
      - I have attended the state-sponsored cost report training for this report (see 1 TAC §355.308(h)).
      - I have read the note below and all the instructions applicable to this report.
      - I have read the Cost Determination Process Rules and Enhanced Direct Care Staff Rate rules applicable
         to this report, which define allowable and unallowable costs and provide guidance in proper reporting.
      - I have reviewed the prior year's report audit adjustments, if any, and have made the necessary revisions
         to this period's report.
      - To the best of my knowledge and belief, this report is true, correct and complete, and was prepared
         in accordance with the Cost Determination Process Rules, Enhanced Direct Care Staff Rate rules and all
         instructions applicable to this report.
      - This report was prepared from the books and records of the contracted provider and/or its controlling entity.


NOTE: This METHODOLOGY CERTIFICATION must be signed by the individual who prepared the report or who has
         the primary responsibility for the preparation of the report. If more than one person prepared the report,
         an executed METHODOLOGY CERTIFICATION may be submitted by each preparer. Misrepresentation or
         falsification of any information contained in this report may be punishable by fine and/or imprisonment.


     As preparer, I acknowledge that failure to properly complete this report in accordance with published
     Cost Determination Process Rules, the Enhanced Direct Care Staff Rate rules, the applicable program-specific
     report instructions, and mandatory cost report training materials may result in the revocation of my
     Mandatory Cost Report Training Certificate and my authority to prepare future Health and Human Services
     Commission reports.



           NAME OF CONTRACTED PROVIDER                        PRINTED/TYPED NAME OF PREPARER



                   TITLE OF PREPARER                               SIGNATURE OF PREPARER
                                                                    (Attach Training Certificates)



                            DATE


         Subscribed and sworn before me, _____________________________, a Notary Public,
         on the ____________day of ______________________________________, _____.


                                                                     NOTARY SIGNATURE


              NOTARY SEAL
                                                                    COMMISSION EXPIRES



                                                                  NOTARY PUBLIC, STATE OF



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