Worksheet S-3 Part IV
- Return to Cost Report Summary
- Form S304
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
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CONCORD, NH 03301
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 |