Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

3990 (Cont.)					FORM CMS 287-05					08-05
STATEMENT OF REVENUE AND EXPENSES										SCHEDULE
										I
					Period
Home Office:					From:				To:
l. Total operating revenue								$
2. Less: Operating expenses
(Schedule B, column 1, line 37)								$
3. Operating profit (loss)								$
4. Other income:
a. contributions, donations						$
b. income from investments						$
c. interest income						$
d. purchase discounts						$
e. rebates and refunds of expenses						$
f. parking lot receipts						$
g. rental income						$
h. other (specify)						$
						$
						$
						$
						$
						$
5. Total other income
(sum of item 4 above)								$
6. Other expenses (specify)						$
						$
						$
						$
						$
7. Total other expenses
(sum of item 6 above)								$
8. Net income (loss) for the period (line 3 plus line 5 minus line 7)								$
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECTION 3918)
39-130										Rev. 1