Facility Name __________________________ VPN or Provider ID_______________ Balance Sheet Date (MO-DA-YR) ______________________ 2018 HCF-4 SCHEDULE 16: DETAIL OF CLERICAL EXPENSES (4140.1) Please provide a description of the Clerical expense. The total must agree with the amount claimed in account (4140.1) on page 14. 2018 Gross Employee Name Job Title Brief Job Description Salary TOTAL (4140.1) SCHEDULE 17: DETAIL OF OTHER ACCOUNTING (4360.3) Provide description of Accounting Expenses claimed in account 4360.3 by using the codes provided below: Part 1: Purchased Service Accounting Date Incurred Vendor Name Amount Brief Description of Expense (MO-DA-YR) Code SUBTOTAL (Part 1) Codes: Type of service/responsibilities A. HCF-4 Prep. D. Personal Tax Prep. G. SEC Filings B. Medicare Cost Rpt. Prep. E. Mgmt.Advisory Serv. H. Other Allow. Acct.-Explain C. Corporate Tax Prep. F. Certified Audit I. Other Non-Allow. Acct.-Explain Part 2: Employee's Responsibilities Only Description of Responsibilities with Employee Name Job Title Salary code and % allocation of time SUBTOTAL (Part 2) TOTAL ACCOUNTING (Part 1 + Part 2) (4360.3) 2018 HCF-4 Page 29
Facility Name __________________________ VPN or Provider ID_______________ Balance Sheet Date (MO-DA-YR) ______________________ 2018 HCF-4 SCHEDULE 16: DETAIL OF CLERICAL EXPENSES (4140.1) Please provide a description of the Clerical expense. The total must agree with the amount claimed in account (4140.1) on page 14. Employee Name Job Title Brief Job Description 2018 Gross Salary TOTAL (4140.1) SCHEDULE 17: DETAIL OF OTHER ACCOUNTING (4360.3) Provide description of Accounting Expenses claimed in account 4360.3 by using the codes provided below: Part 1: Purchased Service Accounting Vendor Name Date Incurred (MO-DA-YR) Amount Code Brief Description of Expense SUBTOTAL (Part 1) Codes: Type of service/responsibilities A. HCF-4 Prep. D. Personal Tax Prep. G. SEC Filings B. Medicare Cost Rpt. Prep. E. Mgmt.Advisory Serv. H. Other Allow. Acct.-Explain C. Corporate Tax Prep. F. Certified Audit I. Other Non-Allow. Acct.-Explain Part 2: Employee's Responsibilities Only Employee Name Job Title Salary Description of Responsibilities with code and % allocation of time SUBTOTAL (Part 2) TOTAL ACCOUNTING (Part 1 + Part 2) (4360.3) 2018 HCF-4 Page 29
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