Form Sr 3 - Group Home Program Costs Report

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
GROUP HOME PROGRAM COSTS REPORT (SR 3)
This form is to collect cost information for the group home program. Report actual allowable and reasonable costs. If the corporation operates more than one group home program
and/or the program provides other services (example: day care, on-site education, adult services, foster family agency, etc.) costs must be allocated to the appropriate activity and
only the allowable group home program costs for the program are to be reported. Describe the methodology used to allocate costs if other than the standard allocation methodology
indicated in current regulations (MPP Section 11-402.8 et seq.) NOTE: A separate cost report form must be completed for each group home program operated by the corporation.
Number of months in cost reporting period _________________________
CORPORATE NAME:
PROGRAM NAME (IF DIFFERENT)
CORPORATE NUMBER PROGRAM NUMBER
PROVIDER FISCAL YEAR
(MO/YR - MO/YR)
A
B
C
D
E
F
COST GROUPS
PERCENTAGE
TOTAL
FINAL COSTS
REASONABLENESS
CDSS USE ONLY
OFFSETS
OF TOTAL
PROGRAM
(COL. A MINUS
ADJUSTMENTS
COSTS
COSTS
COLS. B &C)
$0
0.0%
1
Child Care & Supervision
$0
0.0%
2
Social Work Activities
$0
0.0%
3
Food
0.0%
$0
4a
Shelter Costs - Building Rent & Leases
Shelter Costs - Approved by Attorney General
$0
0.0%
4b
Self-Dealing Transactions Affiliated Leases
$0
0.0%
4c
Shelter Costs - Acquisition Mortgage: Principal & Interest
$0
0.0%
5
Building & Equipment
$0
0.0%
6
Utilities
$0
0.0%
7
Vehicles & Travel
$0
0.0%
8
Child-Related
$0
0.0%
9a
Executive Director Salary
$0
0.0%
9b
Assistance Director Salary
$0
0.0%
9c
Administrator Salary
$0
0.0%
9d
All Other Admin. Salaries
$0
0.0%
9e
Financial Audit Costs
$0
0.0%
9f
Administration (Minus Admin. Salaries and Financial Audit Costs)
0.0%
$0
$0
$0
$0
TOTAL
CDSS USE ONLY
KDE DATE
SR 3 (12/04)

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