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

08-05					FORM CMS 287-05								3990 (Cont.)
ALLOCATION OF HOME OFFICE POOLED COSTS BETWEEN						Home Office:		Period			SCHEDULE
HEALTH CARE FACILITIES AND OTHER CHAIN COMPONENTS								From:			G
								To:			PART I & II
	Part I -- Allocation between Health Care Facilities and Other Components
		Allocation Statistics		Old Capital			New Capital			Non Capital
				Building			Building
		Base:		&	Movable	Interest	&	Movable	Interest	Non-	Interest	Interest
		Total Cost	Ratio	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense	Capital	Expense	Income
		1	1A	2	3	3.01	4	5	5.01	6	7	7.01
1.	Health Care Facilities												1
2.	Other Components												2
	Certain Home Office or Region
	Costs Requiring Home Office/
3.	Region overhead allocation												3
4.	Total												4
Part II -- Allocation to Individual Chain Components
		Allocation Statistics		Old Capital			New Capital			Non Capital
				Building			Building
	Health Care Facilities:	Base:		&	Movable	Interest	&	Movable	Interest	Non-	Interest	Interest
	------------------------------------------		Ratio	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense	Capital	Expense	Income
		1	1A	2	3	3.01	4	5	5.01	6	7	7.01
1													1
2													2
3													3
4
5													5
6													6
7													7
8													8
9													9
10													10
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3917)
Rev. 1													39-127
3990 (Cont.)					FORM CMS 287-05								08-05
ALLOCATION OF HOME OFFICE POOLED COSTS BETWEEN						Home Office:		Period			SCHEDULE
HEALTH CARE FACILITIES AND OTHER CHAIN COMPONENTS								From:			G
								To:			PART I & II (Cont'd)
Part II -- Allocation to Individual Chain Components (Continued)
		Allocation Statistics		Old Capital			New Capital			Non Capital
				Building			Building
	Health Care Facilities:	Base:		&	Movable	Interest	&	Movable	Interest	Non-	Interest	Interest
	(Continued)		Ratio	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense	Capital	Expense	Income
		1	1A	2	3	3.01	4	5	5.01	6	7	7.01
11													11
12													12
13													13
14													14
15													15
16													16
17													17
18	Total (sum of lines 1-17)												18
	Other Components
	-
19													19
20													20
21													21
22													22
23													23
24													24
25													25
26													26
27													27
28	Total (sum of lines 20-27)												28
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3917)
39-128													Rev. 1
08-05					FORM CMS 287-05								3990 (Cont.)
ALLOCATION OF HOME OFFICE POOLED COSTS BETWEEN						Home Office:		Period			SCHEDULE
HEALTH CARE FACILITIES AND OTHER CHAIN COMPONENTS								From:			G
								To:			PART I & II (Cont'd)
Part II -- Allocation to Individual Chain Components (Continued)
		Allocation Statistics		Old Capital			New Capital			Non Capital
				Building			Building
	Regional Offices:	Base:		&	Movable	Interest	&	Movable	Interest	Non-	Interest	Interest
	-----------------------------		Ratio	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense	Capital	Expense	Income
		1	1A	2	3	3.01	4	5	5.01	6	7	7.01
29													29
30													30
31													31
32													32
33	Total (sum of lines 29-32)												33
34	Total (sum of lines 18, 28 and 33)												34
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3917)
Rev. 1													39-129
																																						To: 9-30-92	Part II
																																				Old Capital		New Capital
																																		FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL		Home Office:	Harrod Corporation	Period	SUPPLEMENTAL
																																		COSTS TO CHAIN COMPONENTS---STATISTICS				From: 10-1-91	SCHEDULE F
																																						To: 9-30-92	Part II (Cont'd)
																																					Old Capital		New Capital
																																			Chain Components	Base:	Sq. Ft.		Sq. Ft.
																																				Building		Building
																																				and	Movable	and	Movable
																																			Other Components:	Fixtures	Equipment	Fixtures	Equipment
																																			-	1	2	3	4
																																		18.	Harrod Hotel	8,000	500		12,000
																																		19.
																																		20.
																																		21.
																																		22.
																																		23.
																																		24.
																																		25.
																																		26.	Managed Facilities	8,000	440	2,000	550
																																		27.	Total (sum of lines 18-26)	16,000	940	2,000	12,550
FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,																																			Regional Offices:
	SECTION 3121)																																		-
																																		28.	East Region	3,200	400	750	600
																																		29.	West Region	1,600	330	761	700
																																		30.
																																		31.
																																		32.	Total (sum of lines 28-31)	4,800	730	1,511	1,300
																																		33.	Total statistics (sum of lines 17, 27 and 32)(A)	20,800	1,670	3,511	13,850		0
																																		34.	Cost to be Allocated (B)	Err:520	Err:520	Err:520	Err:520
																																		35.	Unit Cost Multiplier (B/A)	Err:520	Err:520	Err:520	Err:520
																																		FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3134)