Provider Cost Report
This form should be completed semi annually. The first period should cover services provided from July through December of the current year, with the report being submitted by March 15th of the year. The second period should cover services from January through June of the current year, with the report submitted by September 15th of the year.
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Email *
Provider Name: *
CAPS Provider ID:

 *
Contact Name: *
Contact Phone Number: *
Contact Email Address: *
Time Period Covered *
Is the funding and expenses being reported on a cash or accrual basis of accounting? *
Please choose cash basis if revenue and expenses are recognized at the time cash is received or paid out. Please choose accrual basis if revenue is recognized when earned and expenses when incurred. 
Required
Total DSPD revenue for time period:
All revenue received from DSPD including host home and professional parenting revenue should be included on this line. Revenue received from other agencies or other sources should not be included.
Total DSPD revenue for host home or professional parenting services:
Direct service employee wages:
Direct service employees are defined as employees who spend over 60% of their time in direct client care. 
Direct service employees benefits, insurance and payroll taxes (employer share):
Benefit and insurance that would be reported on a W-2  form for an employee should be included. Typical benefits and insurance include medical, dental, vision, workman's compensation and life insurance. Training costs should not be included in this section.
Direct service supervisor wages:
Direct service supervisors are defined as employees who spend over 60% of their time in the supervision of direct service employees. 
Direct service supervisors benefits, insurance and payroll taxes (employer share):
Benefit and insurance that would be reported on a W-2  form for an employee should be included. Typical benefits and insurance include medical, dental, vision, workman's compensation and life insurance. Training costs should not be included in this section.
Payments directly to host home and professional parents:
Respite, direct support and other needed supports should not be included in this section. 
Host home and professional parents benefits, insurance and payroll taxes (employer share):
Benefit and insurance that would be reported on a W-2  form for an employee should be included. Typical benefits and insurance include medical, dental, vision, workman's compensation and life insurance. Training costs should not be included in this section.
Total salary and wages: 
Included all direct service wages, host home, professional parents and administrative wages.
Total employer share of benefits, insurance and payroll taxes:  
Included all direct service wages, host home, professional parents and administrative employer share of benefits, insurance and payroll taxes.   Benefit and insurance that would be reported on a W-2  form for an employee should be included. Typical benefits and insurance include medical, dental, vision, workman's compensation and life insurance. Training costs should not be included in this section.
Total related program expenses:
Please include all directly related program costs including rent, utilities, repairs, maintenance and property insurance for buildings where programs are offered, transportation costs, supplies and materials. Expenses may need to be divide between related program costs and other administrative expenses based on the intended use of the expenses. This section should only include direct program costs.
Other Administrative Expenses:
Please include all other administrative and professional fees including related overhead. Please exclude bad debt, costs of gifts or donations, costs of employee/employer personal use of motor vehicles, penalties/fines, unallowable taxes including federal or state income tax, unallowable advertising expense related to fund-raising, promotional advertising, and publicity, other items not related to providing services, related party profit and personal expenses of owners, shareholders, and key staff that are not related to provided services.
Please list any other business related expenses and amounts that do not fit in one of the categories above:
By answering yes to this question you attest that the information submitted is true, accurate and complete to the best of your knowledge.
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