1. Enter the reporting period of this cost statement.

57431

2. Enter vendor name.

57433 (a)(1)

3. Enter the vendor number, service code, and subcode.

57433 (a)(1)

4. Enter the address where the vendored service is located.

57433 (a)(2)

5. Enter the mailing address for the vendored service.

57433 (a)(2)

6. Enter the name of the management organization, if the service is affiliated with a management organization.

57433 (a)(1)

7. Enter the name of the service director and telephone number for the vendored service.

57433 (a)(3)

57433 (a)(2)

8. Enter the name of the vendoring regional center.

57433 (a)(4)

9. Excluding the vendoring regional center, enter the names of all regional centers for which you provide services.

57433 (a)(4)

10. If you are applying for a temporary payment rate, enter the date you began or intend to begin providing services.

57433 (c)(1)

VENDORS REQUESTING A PERMANENT PAYMENT RATE, COMPLETE LINES 11 THROUGH 21

11 & 12. Enter the total actual number of client days or hours of attendance during this reporting period, from page 2, column 4 or page 3, column 5.

57422 (a)(2)(A) or (B)

13. Enter the total gross salaries and wages, including overtime, and staff relief time for the vendored service.

57434 (a)(1)(A)

13a. Add the total salary and wage and fringe benefits for the direct service function. Divide this total by the total hours of employment for the direct service function. Enter this amount.

57434 (a)(1)(B)

14. Enter the total allowable fringe benefits associated with the salaries and wages on line 13 above.

57434 (a)(2)

15. Enter the total allowable operating expenses from page 4, line 17.

57434 (a)(3)

16. Enter the total allowable management organization costs from page 5, line 2.

57434 (a)(4)

17. Enter the amount from page 6, line 4

57439 (b)

18. Enter the total of lines 13, 14, 15, 16, and 17.

19. Enter the total allowable vendor income from page 5, line 5.

57438

20. Subtract line 19 from line 18.

21. Sign and date Statement of Certification.

57430 (a)

TEMPORARY PAYMENT RATE VENDORS: INCLUDE WITH THE SIGNED COST STATEMENT, A COPY OF THE PROGRAM DESIGN AND VENDOR APPROVAL LETTER.

57433 (c)(2)

PERMANENT PAYMENT RATE VENDORS: INCLUDE WITH THE SIGNED COST STATEMENT, A COPY OF THE PROGRAM DESIGN.

57433 (a)(5)

1.

Enter the number of direct service hours actually provided to clients each month. Direct service hours are defined as the number of hours during which direct services were provided to clients by direct care staff and, for vendors reimbursed for absences, the number of direct service hours for which the vendor received reimbursement.

57210 (a)(3)

2.

Enter the number of days in which the service was actually provided to clients each month, which shall include the number of days for which reimbursement for absences was received.

57433 (b)(2)(C)

3.

Enter the maximum number of clients enrolled each month.

57433 (b)(2)(A)

4.

Enter the actual number of days of attendance each month for all clients, which shall include the the actual number of client days for which reimbursement for absences was received.

57433 (b)(2)(B)

1.

Enter the number of direct service hours actually provided to clients. Direct service hours are defined as the number of hours during which direct services were provided to clients by direct care staff and, for vendors reimbursed for absences, the number of direct service hours for which the vendor received reimbursement.

57210 (a)(3)

2.

Enter the authorized number of direct service hours each month for all clients.

57433 (b)(3)(A)

3.

Enter the number of clients scheduled to receive services each month within the hours identified in column 2.

57433 (b)(3)(B)

4.

Enter the number of clients who actually received services each month within the hours identified in column 2, which shall include the number of clients for whom reimbursement for absences was received.

57433 (b)(3)(C)

5.

Enter the actual number of hours of attendance each month for all clients, which shall include the actual number of hours for which reimbursement for absences was received.

57433 (b)(3)(D)

1.

Enter the cost for accounting fees.

57434 (a)(3)(A)

2.

Enter the cost for bank service fees.

57434 (a)(3)(B)

3.

Enter the communication costs including telephone, telegraph, teletype, centrex, telepak, postage, message service, facsimiles, and TDD.

57434 (a)(3)(C)

4.

Enter the cost for contractual/consultant fees that do not have a specific cost category.

57434 (a)(3)(D)

5.

Enter the depreciation cost excluding vehicle depreciation which is reported on line 16.

57434 (a)(3)(E)

6.

Enter the cost for general expenses. See section referenced for items allowable under general expense.

57434 (a)(3)(F)

7.

Enter the insurance costs.

57434 (a)(3)(G)

8.

Enter the janitorial costs.

57434 (a)(3)(H)

9.

Enter the cost for legal fees.

57434 (a)(3)(I)

10.

Enter the maintenance costs. See section referenced for items allowable under maintenance costs.

57434 (a)(3)(J)

11.

Enter the office and program supplies costs. See section referenced for allowable office and supplies costs.

57434 (a)(3)(K)

12.

Enter the rental and lease costs. See section referenced for items allowable under rental and lease costs.

57434 (a)(3)(L)

13.

Enter the staff training costs.

57434 (a)(3)(M)

14.

Enter the travel costs.

57434 (a)(3)(N)

15.

Enter the utilities costs.

57434 (a)(3)(O)

16.

Enter the vehicle depreciation costs. See referenced section regarding depreciation methodology and useful life.

57434 (a)(3)(P)

17.

Enter the total of lines 1 through 16 here and on page 1, line 15.

1.

Enter the total allowed cost of the management organization.

57434 (a)(4)(C)2.

2.

Enter the amount of management organization costs allocated to this service here and on page 1, line 16.

57434 (a)(4)(C)

3.

Check the method of allocation used.

57434 (a)(4)(C)1.b.

VENDOR INCOME

4.

Enter the name of each source of vendor income, duration of funding, and total income.

57438 (a)

5.

Enter the total of all vendor income here and on page 1, line 19.

57438 (a)

1.

Enter the name of each regional center, total amount of the actual regional center payment received from the regional center, and maximum amount of the regional center payment which you would have received from the regional center based upon the established rate and the units of service actually provided, and the difference between the two amounts.

57439 (a)(2)

2.

Enter the total amount of all actual regional center payments received and the total of all maximum amounts of regional center payments, and the total difference between the two amounts.

57439 (a)(2)

3.

Enter the total amount of cost reductions implemented as a result of the negotiated level of payment.

57439 (b)

4.

Enter the lesser of the amounts entered on line 2D or line 3 here and on page 1, line 17.