Statement of Project Expenses (Schedule B)

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 B
STATEMENT OF PROJECT EXPENSES
FOR MONTH ENDING _________________________  
CHECK ONE:
_____ STATE OFFICE
_____ CHANNELING PROJECT  
_____ SUBCONTRACT
NAME OF PROJECT: _________________________  
SUBCONTRACTOR: _________________________  FUNCTION: _________________________  
STATE: _________________________  
EXPENSE CATEGORY FEDERAL
BUDGET
AMOUNT
(1)
ACTUAL EXPENDITURES FEDERAL REIMBURSABLE EXPENDITURES FEDERAL
BUDGET
REMAINING
(10)
NON-CASH COSTS
(IN-KIND)
CURRENT
MONTH
(2)
ADJUSTMENT
(3)
YEAR-
TO-
DATE
(4)
AM.
PREV.
CLAIMED
(5)
CURRENT
MONTH
(6)
ADJUSTMENT
(7)
YEAR-
TO-
DATE
(8)
CURRENT
MONTH
(10)
YEAR-
TO-
DATE
(11)
1. SALARIES & WAGES                      
2. EMPLOYEE BENEFITS                      
3. RENT                      
4. PRINTING/ COPYING                      
5. OFFICE SUPPLIES                      
6. POSTAGE/ COURIER                      
7. TELEPHONE                      
8. TRAVEL                      
9. EDUCATION/ TRAINING                      
10. MEDICAL ASSESSMENT                      
11. EQUIPMENT RENTAL                      
12. EQUIPMENT ACQUISITION                      
13. CONSULTANTS                      
14. STATE ONLY SUBCONTRACTOR                      
15. OVERHEAD                      
16. OTHER DIRECT COSTS                      
17. SUBTOTAL                      
18. SUBCONTRACTS                      
19. TOTAL                      
REMARKS:
TYPED NAME OF REPORT PREPARER: _________________________  DATE: _________________________  
SIGNATURE: _________________________  TELEPHONE: _________________________  

 

BASIC SITE
SCHEDULE B
STATEMENT OF PROJECT EXPENSES
FOR MONTH ENDING _________________________  
NAME OF PROJECT: _________________________  STATE: _________________________  
EXPENSE CATEGORY FEDERAL
BUDGET
AMOUNT
(1)
ACTUAL EXPENDITURES FEDERAL REIMBURSABLE EXPENDITURES FEDERAL
BUDGET
REMAINING
(9)
CURRENT
MONTH
(2)
ADJUSTMENT
(3)
YEAR-
TO-
DATE
(4)
AM.
PREV.
CLAIMED
(5)
CURRENT
MONTH
(6)
ADJUSTMENT
(7)
YEAR-
TO-
DATE
(8)
1. DAY HEALTH ---                
2. DAY MAINTENANCE ---                
3. HOME HEALTH AIDE ---                
4. HOMEMAKER/ PERS. CARE ---                
5. HOUSEKEEPING ---                
6. CHORE ---                
7. COMPANION ---                
8. HOME DEL. MEALS ---                
9. RESPITE CARE ---                
10. SKILLED NURSING ---                
11. THERAPIES ---                
12. MENTAL HEALTH ---                
13. TRANSPORTATION ---                
14. HOUSING ASSISTANCE ---                
15. ADULT FOSTER CARE ---                
16. NONROUTINE CONSUMABLE MEDICAL SUPPLIES ---                
17. ADAPTIVE AND ASSISTIVE EQUIPMENT ---                
18. EMERGENCY ASSISTANCE (NON-CORE) ---                
19. OTHER (NON-CORE) ---                
20. TOTAL                  

 

COMPLEX SITE
SCHEDULE B
STATEMENT OF PROJECT EXPENSES
FOR MONTH ENDING _________________________  
NAME OF PROJECT: _________________________  STATE: _________________________  
EXPENSE CATEGORY "POOL"
BUDGET
AMOUNT
(1)
ACTUAL EXPENDITURES BUDGET
REMAINING
(5)
CURRENT
MONTH
(2)
ADJUSTMENT
(3)
YEAR-
TO-
DATE
(4)
1. DAY HEALTH          
2. DAY MAINTENANCE          
3. HOME HEALTH AIDE          
4. HOMEMAKER/ PERS. CARE          
5. HOUSEKEEPING          
6. CHORE          
7. COMPANION          
8. HOME DEL. MEALS          
9. RESPITE CARE          
10. SKILLED NURSING          
11. THERAPIES          
12. MENTAL HEALTH          
13. TRANSPORTATION          
14. HOUSING ASSISTANCE          
15. ADULT FOSTER CARE          
16. NONROUTINE CONSUMABLE MEDICAL SUPPLIES          
17. ADAPTIVE AND ASSISTIVE EQUIPMENT          
18. SUBTOTAL OF POOL AMOUNT          
19. EMERGENCY ASSISTANCE (NON-CORE)          
20. OTHER (NON-CORE)          
21. TOTAL          

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