PLEASANT VIEW CENTER
CONCORD, NH  03301

Medicare Provider Number: 305045
Cost report status: Settled Without Audit
[Record Code 1155610 - 2010]

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SNF WAGE RELATED COSTS Provider CCN: 305045
PERIOD:
FROM 10/01/2015
TO 09/30/2016
WORKSHEET S-3 PART IV
PART IV - Wage Related Cost
Part A - Core List Amount Reported  
RETIREMENT COST
1 401k Employer Contributions 1
2 Tax Sheltered Annuity (TSA) Employer Contribution 2
3 Qualified and Non-Qualified Pension Plan Cost 3
4 Prior Year Pension Service Cost 4
PLAN ADMINISTRATIVE COSTS (Paid to External Organizations)
5 401K/TSA Plan Administration fees 5
6 Legal/Accounting/Management Fees-Pension Plan 6
7 Employee Managed Care Program Administration Fees 7
HEALTH AND INSURANCE COST
8 Health Insurance (Purchased or Self Funded) ### 8
9 Prescription Drug Plan 9
10 Dental, Hearing and Vision Plan 10
11 Life Insurance (If employee is owner or beneficiary) 11
12 Accidental Insurance (If employee is owner or beneficiary) 12
13 Disability Insurance (If employee is owner or beneficiary) 13
14 Long-Term Care Insurance (If employee is owner or beneficiary) 14
15 Workers' Compensation Insurance ### 15
16 Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106 Non cumulative portion) 16
TAXES
17 FICA - Employers Portion Only ### 17
18 Medicare Taxes - Employers Portion Only 18
19 Unemployment Insurance ### 19
20 State or Federal Unemployment Taxes ### 20
OTHER
21 Executive Deferred Compensation 21
22 Day Care Cost and Allowances 22
23 Tuition Reimbursement 23
24 Total Wage Related cost (sum of lines 1 -23) ### 24
Part B Other than Core Related Cost Amount Reported  
25 Other Wage Related Costs (specify) OTHER WAGE RELATED COST 25
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.3)
Rev. 7     08-16