Form Sr 4 - Group Home Program Payroll & Fringe Benefit Report
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2STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
GROUP HOME PROGRAM
PAYROLL & FRINGE BENEFIT REPORT (SR 4)
Number of months in cost reporting period: _____
CORPORATE/LICENSEE NAME:
CORPORATE NUMBER:
PROGRAM NUMBER
PROVIDER FISCAL YR
(MO/ YR - MO /YR)
(1)
(2)
(3)
Child Care & Supervision Social Work Activities
CDSS USE ONLY
I.
PAYROLL (DO NOT INCLUDE BENEFITS)
II. FRINGE BENEFIT EXPENSE
1. FICA Employer Tax (include MEDICARE)
2. Unemployment Coverage (State & Federal)
3. Workers’ Compensation Insurance
4. Medical Insurance Expense
5. Retirement
6. Other (Specify on back of form)
TOTAL FRINGE BENEFITS
$0
$0
(Add Lines 1 through 6)
$0
$0
III. TOTAL PAYROLL & FRINGE BENEFITS
IV. CONTRACTOR COSTS
V. TOTAL (Add Line III and Line IV)
Transfer to Column A, Lines 1 and 2, Cost
$0
$0
Report (SR 3)
CDSS USE ONLY
SR 4 (12/04)
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