| 3990 (Cont.) |
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FORM CMS 287-05 |
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08-05 |
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MEDICARE ADJUSTMENTS TO HOME OFFICE EXPENSES |
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SCHEDULE C |
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Home |
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Period |
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Office: |
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From: |
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To: |
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Cost Center to be |
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Adjusted (on |
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* |
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Schedule B, col. 3) |
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Description |
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Line |
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Amount |
No. |
Cost Center |
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1 |
2 |
3 |
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| 1. |
Federal/State income tax, franchise tax and related |
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1. |
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interest and penalties on late payments |
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(CMS Pub. 15-1, secs.2122.2 and 2133) |
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| 2. |
Donations (See CMS Pub. 15-1, Chapter 6) |
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2. |
| 3. |
Stockholders servicing costs (stock transfers and |
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3. |
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registrations) (CMS Pub 15-1, se. 2134.9) |
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| 4. |
Acquisition expenses (CMS Pub. 15-1, sec. 2134.11) |
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4. |
| 5. |
Disposal expenses re: non-patient care assets |
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5. |
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or subsidiaries (CMS Pub. 15-1, sec. 2102.3) |
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| 6. |
Bad Debts (CMS Pub. 15-1, sec. 308) |
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6. |
| 7. |
Life insurance premiums where home office is |
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7. |
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direct/indirect beneficiary (CMS Pub 15-1, sec. 2102.3) |
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| 8. |
Annual stockholder meeting expenses |
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8. |
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(CMS Pub. 15-1, sec. 2134.9) |
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| 9. |
Nonhealth care projects (CMS Pub. 15-1, sec. 2102.3) |
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9. |
| 10. |
Noncompetition agreement expenses |
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10. |
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(CMS Pub. 15-1, sec 2105.1/1218.7) |
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| 11. |
Fund-raising expenses (CMS Pub. 15-1, sec. 2136.2) |
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11. |
| 12. |
Rebates/refunds on expenses (CMS |
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12. |
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Pub. 15-1, sec. 804) |
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| 13. |
Other (Specify) |
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13. |
| 14. |
Cost of ownership of assets leased from related |
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14. |
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organization in lieu of rent (CMS Pub. 15-1, sec. 700) |
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| 15. |
Related organizations (from Schedule D, Part B |
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15. |
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col. 5, line 15 (CMS Pub. 15-1, sec. 700) |
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| 16. |
Value of services of nonpaid |
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16. |
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workers (CMS Pub. 15-1, sec. 700) |
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| 17. |
Interest on Loans between home office and |
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17. |
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components of the chain (CMS Pub. 15-1, |
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sec. 2150.2c) where no exception applies |
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| 18. |
Costs of corporate acquisitions of |
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18. |
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capital stocks and acquisition and |
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development department cost |
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(CMS Pub. 15-1, sec. 2150.2B) |
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| 19. |
Interest on Loans from owners |
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19. |
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(CMS Pub.15-1, sec. 218.2) |
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| 20. |
Abandoned construction in progress |
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20. |
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cost (CMS Pub. 15-1, sec. 2155) |
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| 21 |
Other (specify) |
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21 |
| 22 |
Other (specify) |
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22 |
| 23 |
Other (specify) |
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23 |
| 24 |
Other (specify) |
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24 |
| 25 |
Other (specify) |
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25 |
| 26 |
Other (specify) |
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26 |
| 27 |
Other (specify) |
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27 |
| 28 |
Total (sum of lines 1-27) |
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28 |
| * A. Costs--if cost, including applicable overhead, can be determined. |
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| B. Amount Received--if cost cannot be determined. |
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| FORM CMS-287-05(8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 3911 |
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| 39-112 |
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Rev. 1 |