NEW JERSEY DEPARTMENT OF HUMAN SERVICES Schedule D PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT Center Name: DHS License Number: DO NOT change any preprinted DATA REGARDING RELATED PARTIES Molina Number: wording on this schedule. AND KEY EMPLOYEES Cost Report F.Y.E.: A B C D E F G Loans Reporting Period Transactions Equity Percent Related Party Type Related Party Name Annual Nature of Schedule A of Total Ending Balance Interest Rate Transaction(s) Costs 1 2 3 DATA REGARDING KEY EMPLOYEES INCLUDING RELATED PARTIES H I J K L M O Auto Expense and Related Party? Title Name of Employee Hours Worked Annual Compensation Special Fringe Benefits Other Yes/No Administrator 4 Asst. Administrator 5 Nursing Director 6 RN Supervisor 7 President 8 9 RELATED EMPLOYEE AND/OR WORKS IN MORE THAN ONE PEDIATRIC MEDICAL DAY CARE CENTER OR NURSING FACILITY Name of Employee E. I. Number Name Position(s) Hours Worked Compensation Center’s 10 11 12 13 14
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT DATA REGARDING RELATED PARTIES AND KEY EMPLOYEES Schedule D DO NOT change any preprinted wording on this schedule. A B C D E F G Related Party Type Related Party Name Loans Equity Percent of Total Reporting Period Transactions Ending Balance Annual Interest Rate Nature of Transaction(s) Schedule A Costs 1 2 3 DATA REGARDING KEY EMPLOYEES INCLUDING RELATED PARTIES H I J K L M O Title Name of Employee Hours Worked Annual Compensation Special Fringe Benefits Auto Expense and Other Related Party? Yes/No 4 Administrator 5 Asst. Administrator 6 Nursing Director 7 RN Supervisor 8 President 9 RELATED EMPLOYEE AND/OR WORKS IN MORE THAN ONE PEDIATRIC MEDICAL DAY CARE CENTER OR NURSING FACILITY Name of Employee E. I. Number Center’s Name Position(s) Hours Worked Compensation 10 11 12 13 14
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