Cal. Code Regs. Tit. 17, div. 2, ch. 3, subch. 17, app C to Subchapter 17
Current through Register 2024 Notice Reg. No. 36, September 6, 2024
INSTRUCTIONS
Form DS 1897B (6/94) -- Page 1
| Line | Reference | |
| 1. | Enter the reporting period of this cost statement. | 58031 |
| 2. | Enter vendor name. | 58033 (a)(1) |
| 3. | Enter vendor number, service code, and subcode. | 58033 (a)(1) |
| 4. | Enter the address where the vendored service is located. | 58033 (a)(2) |
| 5. | Enter the mailing address for the vendored service. | 58033 (a)(2) |
| 6. | Enter the name of the management organization, if the service is affiliated with a management organization. | 58033 (a)(1) |
| 7. | Enter the name of the service director and telephone number for the vendored service. | 58033 (a)(3) |
| 58033 (a)(2) | ||
| 8. | Enter the name of the vendoring regional center. | 58033 (a)(4) |
| 9. | Excluding the vendoring regional center, enter the names of all regional centers for which you provide services. | 58033 (a)(4) |
| 10. | If you are applying for a temporary payment rate, enter the date you began or intend to begin providing services. | 58033 (c)(1) |
VENDORS REQUESTING A TEMPORARY PAYMENT RATE, GO TO LINE 20 VENDORS REQUESTING A PERMANENT PAYMENT RATE, COMPLETE LINES 11 THROUGH 20
| 11. | Enter the total actual number of direct service hours provided to clients during this reporting period, and, for vendors reimbursed for absences, the number of direct service hours for which reimbursement was received. | 58033 (b) |
| 12. | Enter the total gross salaries and wages, including overtime, for the vendored service. | 58034 (a)(1) |
| 13. | Enter the cost of allowable fringe benefits associated with the salaries and wages on line 12 above. | 58034 (a)(2) |
| 14. | Enter the total allowable operating expenses from page 2, line 17. | 58034 (a)(3) |
| 15. | Enter the total allowable management organization costs from page 3, line 2. | 58034 (a)(4) |
| 16. | Enter the amount from page 4, line 4. | 58039 (b) |
| 17. | Enter the total of lines 12, 13, 14, 15, and 16. | |
| 18. | Enter the total allowable vendor income from page 3, line 4. | 58038 |
| 19. | Subtract line 18 from line 17. | |
| 20. | Sign and date Statement of Certification. | 58030 (a) |
| TEMPORARY PAYMENT RATE VENDORS: INCLUDE WITH THE | 58033 (a)(5) | |
| SIGNED COST STATEMENT, A COPY OF THE SERVICE | 58033 (c)(2) | |
| DESIGN AND VENDOR APPROVAL LETTER. | ||
| PERMANENT PAYMENT RATE VENDORS: INCLUDE WITH THE | 58033 (a)(5) | |
| SIGNED COST STATEMENT, A COPY OF THE SERVICE DESIGN. | ||
INSTRUCTIONS
Page 2 -- OPERATING EXPENSE DETAIL SHEET
| Line | Reference | |
| 1. | Enter the cost for accounting fees. | 58034 (a)(3)(A) |
| 2. | Enter the cost for bank service fee. | 58034 (a)(3)(B) |
| 3. | Enter the communication costs including telephone, telegraph, teletype, centrex, telepak, postage, message service, facsimiles and TDD. | 58034 (a)(3)(C) |
| 4. | Enter the cost for contractual/consultant fees that do not have a specific cost category. | 58034 (a)(3)(D) |
| 5. | Enter the depreciation cost excluding vehicle depreciation which is reported on line 16. | 58034 (a)(3)(E) |
| 6. | Enter the cost for general expenses. See section referenced for items allowable under general expense. | 58034 (a)(3)(F) |
| 7. | Enter the insurance costs. 58034 | (a)(3)(G) |
| 8. | Enter the janitorial costs. 58034 | (a)(3)(H) |
| 9. | Enter the cost for legal fees. | 58034 (a)(3)(I) |
| 10. | Enter the maintenance costs. See section referenced for items allowable under maintenance costs. | 58034 (a)(3)(J) |
| 11. | Enter the office supplies costs. See section referenced for allowable office supplies costs. | 58034 (a)(3)(K) |
| 12. | Enter the rental and lease costs. See section referenced for items allowable under rental and lease costs. | 58034 (a)(3)(L) |
| 13. | Enter the staff training costs. 58034 | (a)(3)(M) |
| 14. | Enter the costs for staff travel. | 58034 (a)(3)(N) |
| 15. | Enter the utilities costs. | 58034 (a)(3)(O) |
| 16. | Enter the vehicle depreciation costs. See referenced section regarding depreciation methodology and useful life. | 58034 (a)(3)(P) |
| 17. | Enter total of lines 1 through 16 here and on page 1, line 14. | |
INSTRUCTIONS
Page 3 -- MANAGEMENT ORGANIZATION COST AND VENDOR INCOME DETAIL SHEET
MANAGEMENT ORGANIZATION COST
| Line | Reference | |
| 1. | Enter the total allowed cost of the management organization. | 58034 (a)(4)(C)2. |
| 2. | Enter the amount of management organization costs allocated to this service here and on page 1, line 15. | 58034 (a)(4)(C) |
| 3. | Check the method of allocation used. | 58034 (a)(4)(C)1.a. |
| 58034 (a)(4)(C)1.b. | ||
VENDOR INCOME
| Line | Reference | |
| 4. | Enter name of each source of vendor income, duration of funding and total income. | 58038 (a) |
| 5. | Enter the total of all vendor income here and on page 1, line 18. | 58038 (a) |
INSTRUCTIONS
Page 4 -- REGIONAL CENTER PAYMENT INFORMATION DETAIL SHEET
APPLICABLE ONLY TO VENDORS WHO NEGOTIATED A LOWER LEVEL OF PAYMENT
Regional Center Payment Information
| Line | Reference | |
| 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 actual units of service provided, and the difference between the two amounts. | 58039 (a)(1) 58039 (a)(2) |
| 2. | Enter the total amount of all actual regional center payments received, the total of all maximum amounts of regional center payments, and the total difference between the two amounts. | 58039 (a)(1) 58039 (a)(2) |
| 3. | Enter the total amount of cost reductions implemented as a result of the negotiated level of payment. | 58039 (b) |
| 4. | Enter the lesser of the amounts entered on line 2D or line 3 here and on page 1, line 16. | |
Cal. Code Regs. Tit. 17, div. 2, ch. 3, subch. 17, app C to Subchapter 17