Schedule E NEW JERSEY DEPARTMENT OF HUMAN SERVICES Center Name: PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT DHS License Number: DO NOT change any preprinted Molina Number: RECONCILIATION wording on this schedule. Cost Report F.Y.E.: A B C D SCHEDULE COLUMN LINE AMOUNT EXPENSES Total Gross Salaries Reported 1 Total Gross Salaries per Form 941 2 Difference Line (Line 1 less Line 2) 3 Explanations of Line 3 4 5 6 7 Total Expenses Reported 8 Total Expenses Per Financial Statements 9 Difference Line (Line 8 less Line 9) 10 11 Explanations of Line 10 12 13 14 15 TOTAL 16 REVENUES Routine Revenues B 1 Incidental Revenues 2 Other Operating Revenues 3 SCHEDULE 4 5 Total Revenues Reported Total Revenues per Financial Statements 6 Difference Line (Line 5 less Line 6) 7 Explanations of Line 7 8 9 10 11 TOTAL 12
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 RECONCILIATION Schedule E DO NOT change any preprinted wording on this schedule. A B C D SCHEDULE COLUMN LINE AMOUNT EXPENSES 1 Total Gross Salaries Reported 2 Total Gross Salaries per Form 941 3 Difference Line (Line 1 less Line 2) 4 Explanations of Line 3 5 6 7 8 Total Expenses Reported 9 Total Expenses Per Financial Statements 10 Difference Line (Line 8 less Line 9) 11 Explanations of Line 10 12 13 14 15 16 TOTAL REVENUES 1 Routine Revenues B 2 Incidental Revenues 3 Other Operating Revenues 4 SCHEDULE 5 Total Revenues Reported 6 Total Revenues per Financial Statements 7 Difference Line (Line 5 less Line 6) 8 Explanations of Line 7 9 10 11 12 TOTAL
(F)%20PRN%202016-209%20(DHS-DAS%2010_166).docx