Statement of Funds Applied (Schedule A)

06/26/2012

This instrument was developed for the National Long-Term Care Channeling Demonstration. This project was conducted by Mathematica Policy Research, Inc. under contract #HHS-100-80-0157 and Temple University under contract #HHS-100-80-0133 for the Department of Health and Human Services (HHS) Office of Social Services Policy (now Office of Disability, Aging and Long-Term Care Policy), as well as additional funding from the HHS Health Care Financing Administration (now Centers for Medicare and Medicaid Services) and HHS Administration on Aging. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.


NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form.

 

SCHEDULE A
STATEMENT OF FUNDS APPLIED FOR QUARTER ENDING _________________________  
Check One _____ State
_____ Channeling Project
Project Name _________________________  
State _________________________  
Specify Year Beginning For:
Site Operations Funds  /___/___/___/
Direct Service Funds  /___/___/___/
Fund Sources Type of Use
Site of State Operations* Direct Services*
Funds This Quarter Year to Date Funds This Quarter Year to Date
A. Medicare: ODR (Complex Sites Only) / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /    
B. Cash and Accruals (Non Federal)        
   State and Local Government (specify)          
      1.        
      2.        
      3.        
   Private Contributions (specify)        
      1.        
      2.        
   Client Payments (Complex Sites Only) --- ---    
   Other (specify)        
      1.        
      2.        
C. Total Cash and Accruals and Medicare Funds        
D. In-Kind Contributions     / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
   State and Local Government (specify)     / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
      1.     / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
      2.     / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
   Private Contributions     / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
   Other     / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
E. Total In-kind Contributions     / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /
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