Financial Information Survey - (Rev. 1, 08-30-02)

230.9 - Financial Information Survey - (Rev. 1, 08-30-02) A1-1255.9, B1-4255.9 This survey must be completed and submitted in hard copy as an attachment to the contractor's initial BR. If the contractor has a new severance policy in place or its previous severance policy has been updated, it shall: • State the effective date for the new or updated severance policy. • Summarize its severance/separation pay policy including both management and staff. State the length of service criteria, types of cost covered by the policy, the effective date of the policy and any other criteria used in determining the amount of payment. Identify and discuss any related benefits which may be payable to or on behalf of the employee beyond the standard severance payment(s). • Attach a dated extract of its corporate severance pay policy and any related benefits payable to or on behalf of the employee related to the severance or separation. • If there is no change since the submission of the initial BR for last year, state "No Change." The contractor shall estimate the number of direct Medicare employees (excluding temporaries) in this BR FY, the average number of years that staff and management have been employed full time on the Medicare contract and average number of years each has been with the corporation: • No. of direct Medicare employees: Staff _____ Management _____ • Avg. yrs. employed Full Time with Medicare: Staff _____ Management _____ • Avg. yrs. employed with corporation: Staff _____ Management _____ The contractor shall indicate whether, during the last two years or for this BR, it has acquired or intends to acquire (through lease or purchase) any Electronic Data Processing Equipment (as reported on the Cost Classification Report, see §180.4) or any EDP operations change which will result in a TOTAL charge (not annual depreciation) to the Medicare program exceeding $500,000? Yes or No _________ If yes, it shall state the following: • Month and year of acquisition: • Type of acquisition (new lease, replacement lease, purchase): • Reason for acquisition (obsolescence, overcapacity): • Amount included in this BR for the equipment or operations change: $_______. • Total number of depreciable years _________ • Number of depreciable years remaining:__________ NOTE: Any response to the above does not constitute prior notice/approval as required by the contract. The contractor shall provide a breakdown of the "average un-depreciated balance of assets" allocated to Medicare as included in the Cost Classification Report (CCR) for this BR (See §180.51.) Facilities or Occupancy: $ ______ Furniture and Equipment: $ ______ Electronic Data Processing Equipment: $ ______ Other (specify): $ ______ Total (agree to CCR): $ ______ The contractor shall identify all leases or rentals in effect in this BR FY for facilities/occupancy, furniture and equipment, EDP equipment, and Other where the annual charge to Medicare for this BR FY will equal or exceed $500,000. It shall provide the annual amount included in the FY BR and lease/rental expiration month and year. If none, it shall state none. NOTE: The contractor's RO may require a listing of all subcontracts/leases for review. The contractor shall contact its RO if it is in doubt. In conjunction with the facilities and occupancy costs, provided as Item 3 on the Cost Classification Report, the contractor shall summarize the Medicare costs by general categories below. It shall include base and budget period costs: It shall complete the following information: Indicate Base Period you are using: ___________ 1. Depreciation and Rent or Lease: • Depreciation Base Period:_______ Budget Year: _______ (Use when buildings and land are owned. Building costs are total costs excluding interest expenses, but including parking lots, landscaping, etc.) • Rent or Lease: Base Period: _______ Budget Year: _______ (Use when facilities are rented either from an outside source or an affiliate. These costs include amortization of leasehold improvements.) 2. Utility Costs: Base Period: _______ Budget Year:________ (Report power, heat, and light for owned space and where not included in rental or lease costs.) 3. Other Costs: Base Period: _______ Budget Year: _______ (This includes items such as janitorial services, security, carpentry, plumbing, electrical and all work associated with non-permanent type partitioning and moving operations within the building, if not included in the rental or lease cost.) 4. Total Costs: Base Period: _______ Budget Year: _______ (Total cost of 1 through 3 to agree with Facility and Occupancy costs reported on the Cost Classification Report.) 5. Cost Per Net Usable Square Foot: See Appendix B, Article X.B. of the Medicare contract/agreement for the definition of net usable space. Base Year: Total Cost: ______ Square Feet: _____ Cost Per Sq. Foot: ____ Budget Year: Total Cost: ______ Square Feet: _____ Cost Per Sq. Foot: ____