Child Placing Agency (CPA) Cost Report
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1 Child Placing Agency (CPA) Cost Report Reporting Period: 1/1/2011 to: 12/31/2011 VENDOR Vendor Name Street Address City State Zip Code Telephone Number Agency Type License Facility Type Federal Tax Identification Number / EIN KidTraks Vendor ID IRate Cost Report ID Days of Operation Child Placing Agency 1.1 Programs Level of Care Name Rate Listing ID Category of Supervision Name DCS Payment Rate Utilization Payments to Foster Parents Average Payment to Foster Parents Totals: CONTACTS Name of Person Completing Report Title Signature Date Telephone Number Fax Number Address Name of Vendor Authorized Representative Title Signature Date Telephone Number Fax Number Address CPA Programs 1 of 1
2 Cost Entry 3.1 Salaries and Wages Total Administrative Adoption Time Study Non IVE (IL & Recreation) Behavioral Health Medical Education Unallowable FTE FTE % FTE % FTE % FTE % FTE % FTE % FTE % FTE % Total Fringe Benefits & Payroll Taxes Social Security & Medicare Workers Compensation Unemployment Insurance Retirement Health, Dental, Vision, etc. Life Insurance Disability Insurance Other Fringe Benefits & Payroll Taxes Total Contracted Services Other Contracted Services Total Time Study Cost Allocation Administrative Adoption Case Management Non IVE (IL & Recreation) Behavioral Health Medical Education Unallowable FTE % FTE % FTE % FTE % FTE % FTE % FTE % FTE % 3.1 Salaries and Wages Fringe Benefits & Payroll Taxes 19.19% 1.32% 75.00% 0.00% 2.85% 0.79% 0.32% 0.53% 3.3 Contracted Services Personnel Cost By Activity Type 3.1 Salaries and Wages Fringe Benefits & Payroll Taxes 3.3 Contracted Services Total Personnel CPA Personnel Costs 1 of 1
3 Cost Entry Total Administrative Adoption Case Management Non IVE (IL & Recreation) Behavioral Health Medical Education Unallowable 4.1 Child/Resident % % % % % % % % Food Clothing School Supplies & Fees Household Supplies Medicine Chest Items Medical/Prescriptions/Testing Personal Incidentals Program Supplies Liability Insurance Other Child/Resident Total 4.2 Operating Food/Household Supplies Office Supplies Fees, Dues, & Subscriptions Accident Insurance Advertising Printing/Postage/Shredding Conference & Training Employee Medical Exams Employee Recruitment Bad Debt Other Operating Total 4.3 Occupancy Depreciation (Building & Grounds) Depreciation (Equipment) Rent Mortgage Interest Property Taxes Property Insurance Utilities Telephone Maint. & Repair (Building & Grounds) Maintenance & Repair (Equipment) Small Equipment Purchase Leased and Rented Equipment Other Occupancy Total 4.4 Travel Gas, Oil, Maintenance & Repair Staff Mileage Auto Insurance Conference / Training (Travel) Purchased Transportation (Child) Other Travel Total Total Program CPA Program Costs 1 of 1
4 Cost Entry Total Adoption Case Management Non IVE (IL & Recreation) Behavioral Health Medical Education Unallowable 5.1 Indirect Personnel FTE FTE % FTE % FTE % FTE % FTE % FTE % FTE % Senior Management General Administrative Human Resources Finance Facilities Management Management Information Systems / Development Other Indirect Personnel Total Indirect Operating Food/Household Supplies Office Supplies Fees, Dues, & Subscriptions Accident Insurance Advertising Printing/Postage/Shredding Conference & Training Employee Medical Exams Bad Debt Depreciation (Building & Grounds) Depreciation (Equipment) Rent Mortgage Interest Property Taxes Property Insurance Utilities Telephone Maint. & Repair (Building & Grounds) Maintenance & Repair (Equipment) Small Equipment Purchase Leased and Rented Equipment Gas, Oil, Maintenance & Repair Staff Mileage Auto Insurance Conference / Training (Travel) Management Fees Other Indirect Operating Total Total Indirect CPA Indirect Costs 1 of 1
5 Payer / Revenue Source Per Diem Payments / / Total Case Management Adoption Behavioral Health Medical Education Other AddOns % % % % % % % % 6.1 Direct Program Revenue Indiana DCS Indiana DOC Indiana DOE Indiana FSSA Private Pay Medicaid USDA National School Lunch Program Other Direct Program Revenue Total 6.2 Indirect Revenue Interest Medicaid Rent Other Indirect Revenue Total Total Revenue CPA Revenue 1 of 1
6 Cost Entry "Other" Cost Entry Description Other Fringe Benefits & Payroll Taxes Other Contracted Services Other Child/Resident Other Operating Other Occupancy Other Travel Other Indirect Personnel Other Indirect Operating Other Direct Program Revenue Other Indirect Revenue Total Small Equipment Purchase Schedule Total Small Equipment Purchase Notes Subtotal Small Equipment Purchase Leased and Rented Equipment Schedule Total Leased and Rented Equipment Subtotal Leased and Rented Equipment CPA Attachment 1 of 1
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