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					SCDHHS - COMMUNITY LONG TERM CARE SERVICES - GENERAL INFORMATION
PROVIDER NAME:
COST REPORT PERIOD FROM:                             TO:

1.       PROVIDER DATA:
      a. NAME                                                                   EIN:
         PROVIDER LOCATION (STREET ADDRESS):
         MAILING ADDRESS (STREET OR P.O. BOX):
         CITY:                                                   STATE/ZIP:
         PHONE (AREA CODE):                                      FAX # :

      b. CONTROL TYPE:            FOR - PROFIT
                                  NON - PROFIT
                                  GOVERNMENT

2.      DIRECTOR DATA:

3.      IF YOU HAVE AN ACCOUNTING FIRM, PLEASE COMPLETE:
        ACCOUNTING FIRM:
        ADDRESS:
        PHONE:

4.      REPORT PREPARER: GIVE THE NAME AND TITLE OF THE PERSON COMPLETING THIS FORM.
        NAME:
        ADDRESS:
        PHONE:

5.      PROVIDER OPERATOR AND COST REPORT PREPARER CERTIFICATION
        Under penalties of perjury, I declare that I have examined this cost report, including any accompanying schedule and/or
        statement, and to the best of my knowledge and belief, it is true, accurate, and complete. Declaration of the preparer
        (other than provider owners/personnel) is based on all information of which preparer has knowledge.



                     Owner's (Director's) Signature                                    Report Preparer's Signature
        Date:                                                               Date:




     Rev. 04/05                                                          Page 1 of 11                         26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - GENERAL INFORMATION
PROVIDER NAME:
COST REPORT PERIOD FROM:                                             TO:

6.    OPERATING OWNER(S) [OWNER OF CURRENTLY LICENSED BUSINESS]:
      (If more than one owner, attach schedule of addresses and precent of ownership for each owner.)

      NAME:
      ADDRESS:
      PHONE:

7.    OWNER'S COMPENSATION: (Compensation would include salaries, bonuses, personal use of business vehicles, etc.)

                                                                   TOTAL                              COST REPORT              Did you claim
           OWNER(S) NAME                    JOB TITLE             HOURS         COMPENSATION           REFERENCE         compensation for another
                                                                  WORKED          AMOUNT                LINE, PAGE         service or program? *




8.    RELATIVE'S COMPENSATION: (Compensation would include salaries, bonuses, personal use of business vehicles, etc.)

                                                                   TOTAL                              COST REPORT              Did you claim
           RELATIVE'S NAME                  JOB TITLE             HOURS         COMPENSATION           REFERENCE         compensation for another
                                                                  WORKED          AMOUNT                LINE, PAGE         service or program? *




      * - If compensation is claimed in another service or program, the other service or program has to be identified.
           Attach additional pages as may be necessary.




                                                                             Page 2 of 11
     Rev. 04/05                                                                                                 26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - GENERAL INFORMATION
PROVIDER NAME:
COST REPORT PERIOD FROM:                                                      TO:



9. WHICH OF THE FOLLOWING CLTC SERVICES DO YOU PROVIDE?

           CLTC SERVICE:                      Provider Number(s):
Adult Day Health Care Services:
Adult Day Health Care Nursing Services:
Personal Care I Services:
Personal Care II Services:
Medicaid Nursing:
Other (Specify):

If you need additional space, attach additional pages as may be necessary.


10. DOES THE PROVIDER DO BUSINESS WITH OTHER BUSINESSES OWNED BY THE OWNER? (Includes a related party lease)

NO - If no, YOU DO NOT NEED TO COMPLETE THIS SECTION.
YES - If yes, the following information must be completed.

EXPENSES (SUPPLIES, RENT, MANAGEMENT FEES, ETC.)
                                                                              COST        COST        COST REPORT
     RELATED BUSINESS NAME                    ITEM DESCRIPTION               TO THE      TO THE        REFERENCE
                                                                              CLTC    RELATED PARTY     LINE, PAGE




       Rev. 04/05                                                             Page 3 of 11              26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - INCOME AND UNITS OF SERVICE PROVIDED
PROVIDER NAME:
COST REPORT PERIOD FROM:                                                                                 TO:

ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If the provider's accounting system identifies various revenue and expenditure sources by account numbers, please
include these account numbers below.

            ACCOUNT                                                                                                                                TOTAL
            NUMBER*                                                                                                                               INCOME
                      INCOME                               ADHC       ADHC NURSING         PC-I         PC-II          MN           OTHER
     1.               INCOME-PRIVATE                                                                                                                      $0
     2.               INCOME-MEDICAID                                                                                                                     $0
     3.               CONTRIBUTIONS INCOME                                                                                                                $0
     4.               VENDING MACHINE INCOME                                                                                                              $0
     5.               INTEREST INCOME                                                                                                                     $0
     6.               RENTAL INCOME                                                                                                                       $0
     7.               OTHER INCOME (specify)                                                                                                              $0
     8.      TOTAL INCOME:                                       $0                $0             $0            $0           $0           $0              $0



SERVICE INFORMATION:

                                                           ADHC       ADHC NURSING         PC-I         PC-II          MN           OTHER         TOTAL
      9.   TOTAL NUMBER OF CLIENTS SERVED:                                                                                                                 -
     10.   NUMBER OF MEDICAID CLIENTS SERVED:                                                                                                              -
     11.   TOTAL NUMBER OF UNITS PROVIDED:                                                                                                                 -
     12.   NUMBER OF MEDICAID UNITS PROVIDED:                                                                                                              -

Notes:



1.         If you have "OTHER INCOME", please provide a narrative explanation in the "Notes" section above.
2.         A unit of service for ADHC is a day, which must consist of a minimum of 5 hours at the facility for CLTC clients. However, a day may
           be less than 5 hours for DDSN MR/RD clients. A unit for PC-I, PC-II, and/or MN services is one hour.
           An ADHC provider can bill one ADHC Nursing unit per day.




           Rev. 04/05                                                       Page 4 of 11                    26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - ADMINISTRATION EXPENSES
PROVIDER NAME:
COST REPORT PERIOD FROM:                                                                                                TO:

ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If the provider's accounting system identifies various revenue and expenditure sources by account numbers, please
include these account numbers below.
          ACCOUNT                                                                                                                                                    TOTAL
          NUMBER*                                              ADHC      ADHC NURSING          PC-I          PC-II                        MN            OTHER        COST
                       ADMINISTRATION EXPENSES
   1.                  DIRECTOR SALARY                                                                                                                                       $0
   2.                  BOOKKEEPING SALARIES                                                                                                                                  $0
   3.                  ADMINISTRATIVE ASST SALARY                                                                                                                            $0
   4.                  ADVERTISING                                                                                                                                           $0
   5.                  PURCHASED SERVICES                                                                                                                                    $0
   6.                  PRINTING & COPIER EXPENSE                                                                                                                             $0
   7.                  OFFICE SUPPLIES & POSTAGE                                                                                                                             $0
   8.                  PROFESSIONAL ACCOUNTING                                                                                                                               $0
   9.                  PROFESSIONAL- OTHER                                                                                                                                   $0
  10.                  TELEPHONE                                                                                                                                             $0
  11.                  SEMINARS & TRAINING                                                                                                                                   $0
  12.                  MANAGEMENT FEES                                                                                                                                       $0
  13.                  FACILITY REPAIRS                                                                                                                                      $0
  14.                  FACILITY MAINTENANCE                                                                                                                                  $0
  15.                  BANK/FREIGHT CHARGES                                                                                                                                  $0
  16.                  SMALL EQUIPMENT (< $5,000)                                                                                                                            $0
  17                   ADMINISTRATION OTHER                                                                                                                                  $0
  18.                  LEGAL FEES                                                                                                                                            $0
  19.                                                                                                                                                                        $0
                       EMPLOYEE BENEFITS/FRINGES
  20.                  FICA, FUTA, SUTA EXPENSE                                                                                                                              $0
  21.                  WORKER'S COMPENSATION                                                                                                                                 $0
  22.                  HEALTH & LIFE INSURANCE                                                                                                                               $0
  23.                  OTHER (SPECIFY)                                                                                                                                       $0
  24.                  TOTAL ADMIN EXPENSES                           $0              $0             $0              $0                            $0           $0           $0


Notes:

** Please detail expenses and amounts claimed as "Professional-Other", "Administration-Other", or "Other" benefits in the "Notes" section above.




                                                                                     Page 5 of 11
         Rev. 04/05                                                                                                       26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - DIRECT CARE EXPENSES
PROVIDER NAME:
COST REPORT PERIOD FROM:                                                                                                 TO:

ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If the provider's accounting system identifies various revenue and expenditure sources by account numbers, please
include these account numbers below.
          ACCOUNT                                                                                                                                                          TOTAL
          NUMBER*                                                ADHC      ADHC NURSING          PC-I          PC-II                       MN             OTHER            COST
                       DIRECT CARE EXPENSES
   1.                  SUPERVISOR SALARIES                                                                                                                                         $0
   2.                  NURSES                                                                                                                                                      $0
   3.                  AIDES SALARIES                                                                                                                                              $0
   4.                  DRIVER(S), if applicable                                                                                                                                    $0
   5.                  COOK(S), if applicable                                                                                                                                      $0
   6.                  SUPPLIES                                                                                                                                                    $0
   7.                  FACILITY TRANSPORTATION                                                                                                                                     $0
   8.                  TRAVEL REIMBURSEMENT                                                                                                                                        $0
   9.                  CONTRACT TRANSPORTATION                                                                                                                                     $0
  10.                  CONTRACTED MEALS                                                                                                                                            $0
  11.                  EMPLOYEE UNIFORM EXPENSE                                                                                                                                    $0
  12.                  EMPLOYEE BLOOD/SKIN TEST                                                                                                                                    $0
  13.                  SMALL EQUIPMENT EXPENSE                                                                                                                                     $0
  14.                  OTHER (SPECIFY)**                                                                                                                                           $0
                       EMPLOYEE BENEFITS/FRINGES
  15.                  FICA, FUTA, SUTA EXPENSE                                                                                                                                    $0
  16.                  WORKER'S COMPENSATION                                                                                                                                       $0
  17.                  HEALTH & LIFE INSURANCE                                                                                                                                     $0
  18.                  OTHER (SPECIFY)                                                                                                                                             $0
  19.                  TOTAL DIRECT SERVICES                            $0             $0             $0              $0                         $0                   $0           $0


Notes:

** Provide a narrative explanation in the "Notes" section above for "Other" expenses and/or "Other" benefits and fringes. Use additional pages as may be necessary.




                                                                                    Page 6 of 11
         Rev. 04/05                                                                                                      26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - UTILITIES, TAXES, INSURANCE & LICENSES EXPENSES
PROVIDER NAME:
COST REPORT PERIOD FROM:                                                                                            TO:

ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If the provider's accounting system identifies various revenue and expenditure sources by account numbers, please
include these account numbers below.
(1) NOTE: State and Federal income taxes should not be included under this section, but under "NON-ALLOWABLE" on Page 8.
          ACCOUNT                                                                                                                                                   TOTAL
          NUMBER*                                              ADHC      ADHC NURSING          PC-I          PC-II                    MN               OTHER        COST
                       UTILITIES
   1.                  HEATING                                                                                                                                              $0
   2.                  ELECTRICITY                                                                                                                                          $0
   3.                  WATER                                                                                                                                                $0
   4.                  SEWER                                                                                                                                                $0
   5.                  GARBAGE                                                                                                                                              $0
   6.                  UTILITIES-OTHER**                                                                                                                                    $0
   7.                  TOTAL UTILITIES                                $0              $0             $0              $0                      $0                $0           $0



                      TAXES/INSURANCE/LICENSES                  ADHC         ADHC NURSING          PC-I             PC-II             MN               OTHER        TOTAL
   8.                 PROPERTY TAX EXPENSE                                                                                                                                  $0
   9.                 BUSINESS TAX                                                                                                                                          $0
  10.                 INSURANCE-PROPERTY                                                                                                                                    $0
  11.                 INSURANCE-LIABILITY                                                                                                                                   $0
  12.                 INSURANCE-GENERAL                                                                                                                                     $0
  13.                 LICENSES                                                                                                                                              $0
  14.                 OTHER (SPECIFY)**                                                                                                                                     $0
  15.                 TOTAL TAXES,INS & LICENSES                        $0               $0               $0                $0               $0                $0           $0


Notes:

** Provide a narrative explanation for any expenses for "UTILITIES-OTHER" and/or "OTHER" taxes, insurance and licenses in the "Notes" section above.
Use additional pages as may be necessary.




         Rev. 04/05                                                               Page 7 of 11
                                                                                                                       26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - COST OF CAPITAL & NON-ALLOWABLE EXPENSES
PROVIDER NAME:
COST REPORT PERIOD FROM:                                                                                          TO:

ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If the provider's accounting system identifies various revenue and expenditure sources by account numbers, please
include these account numbers below.
         ACCOUNT
         NUMBER*
                     COST OF CAPITAL                                  ADHC    ADHC NURSING          PC-I          PC-II         MN          OTHER        TOTAL
   1.                DEPRECIATION-LAND IMPROVEMENTS                                                                                                              $0
   2.                DEPRECIATION-BUILDING                                                                                                                       $0
   3.                DEPRECIATION- EQUIPMENT/FURNITURE                                                                                                           $0
   4.                BUILDING-RENT EXPENSE                                                                                                                       $0
   5.                EQUIPMENT & FURNITURE-RENT                                                                                                                  $0
   6.                INTEREST-BUILDING                                                                                                                           $0
   7.                INTEREST - EQUIPMENT & FURNITURE                                                                                                            $0
   8.                INTEREST- OTHER**                                                                                                                           $0
   9.                TOTAL COST OF CAPITAL                                 $0              $0            $0              $0            $0           $0           $0


                   NON-ALLOWABLE EXPENSES                           ADHC        ADHC NURSING      PC-I           PC-II          MN          OTHER        TOTAL
  10.              VENDING MACHINE EXPENSE                                                                                                                       $0
  11.              FEDERAL INCOME TAX                                                                                                                            $0
  12.              STATE INCOME TAX                                                                                                                              $0
  13.              CONTRIBUTIONS                                                                                                                                 $0
  14.              FINES & PENALTIES                                                                                                                             $0
  15.              BAD DEBTS                                                                                                                                     $0
  16.              LOBBYING EXPENSES                                                                                                                             $0
  17.              OTHER NON-ALLOWABLE                                                                                                                           $0
  18.              TOTAL NON-ALLOWABLE                                     $0             $0             $0              $0            $0           $0           $0


Notes:

** Include a narrative explanation for "INTEREST-OTHER" expenses and/or "OTHER NON-ALLOWABLE" expenses in the "Notes" section above.




                                                                                Page 8 of 11
         Rev. 04/05                                                                                             26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - LOAN PAYMENTS AND MAJOR EQUIPMENT PURCHASES
PROVIDER NAME:
COST REPORT PERIOD FROM:                                      TO:


                                                   ENDING                                    COST REPORT                        NAME OF
                                   INTEREST        BALANCE            INTEREST PD             REFERENCE                         LENDING                      REASON FOR
         TYPE DEBT                   RATE          @                                       PAGE       LINE                    INSTITUTION                     FINANCING




           TOTAL                                                 $0                $0




ASSET ADDITION SCHEDULE:
                                                                      ACQUISITION       HISTORICAL      ESTIMATED           DEPRECIATION
                                CLASSIFICATION                           DATE              COST            LIFE               EXPENSE
ASSET ADDITIONS




 TOTAL ASSET ADDITIONS                                                                             $0                                           $0


* Attach a narrative explanation of the service(s) benefitting from such mortgages/loans and/or purchases. Explain the basis of allocation of the expenses
between services. Use additional pages as may be necessary.




                                                                                 Page 9 of 11
        Rev. 04/05                                                                                                26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - PERSONNEL SCHEDULE
PROVIDER NAME:
COST REPORT PERIOD FROM:                                                          TO:


                                 TOTAL                         TOTAL                               Salary allocated based on % of time spent in specified areas.
                                HOURS          HOURLY        SALARY OR                            (Attach a narrative explanation of the basis of each allocation.)
        POSITION *              WORKED          WAGE           WAGES             ADMIN            ADHC        ADHC NURSING           PC-I            PC-II          MN          OTHER
           (1)                     (2)           (3)             (4)              (5)               (6)              (7)              (8)             (9)           (10)         (11)




           TOTAL                                                         $0              $0              $0                  $0              $0               $0           $0       $0




* List each type of position which is utilized in your CLTC program. If there are a number of employees that occupy the same position, include the number
of employees in that position. List provider personnel first. Then, total the provider personnel. If personnel are contract employees, then each type of
contracted position needs to be listed in the same manner as the provider personnel. Total the contracted positions. Give the grand total of all personnel.




                                                                                     Page 10 of 11
        Rev. 04/05                                                                                                         26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls
SCDHHS - CLTC SERVICES - SUMMARY
PROVIDER NAME:
COST REPORT PERIOD FROM:                                                                     TO:



       PAGE   LINE           INCOME               ADHC        ADHC NURSING       PC-I        PC-II        MN         OTHER        TOTAL
 1.      4      8  TOTAL INCOME                                                                                                           $0



       PAGE   LINE             EXPENSES           ADHC        ADHC NURSING       PC-I        PC-II        MN         OTHER        TOTAL
 2.      5     25    ADMINISTRATION EXPENSES                                                                                              $0
 3.      6     19    DIRECT SERVICES EXPENSES                                                                                             $0
 4.      7      7    UTILITIES                                                                                                            $0
 5.      7     15    TAXES,INSURANCE & LICENSES                                                                                           $0
 6.      8      9    COST OF CAPITAL                                                                                                      $0
 7.      8     18    NON-ALLOWABLE EXPENSES                                                                                               $0
 8.                  TOTAL EXPENSES                      $0            $0               $0           $0        $0            $0           $0



       PAGE   LINE       NET SURPLUS or (LOSS)    ADHC        ADHC NURSING       PC-I        PC-II        MN         OTHER        TOTAL
 9.                  NET SURPLUS or (LOSS)                                                                                                $0



       PAGE   LINE            UNITS               ADHC        ADHC NURSING       PC-I        PC-II        MN         OTHER        TOTAL
 10.     4     12 TOTAL UNITS                                                                                                              -




                                                                 Page 11 of 11
       Rev. 04/05                                                                             26e0eba0-6b1b-42c4-9175-20e50cdc54e8.xls

				
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Description: Private Lending Interest Contract Template document sample