Preparation of State Agency Schedule for Equipment Purchase,

4614 - Preparation of State Agency Schedule for Equipment Purchase, Form CMS-1466 (Exhibit 54) (Rev. 1, 05-21-04) A. Usage This form is applicable for both LTC and non-LTC equipment requests and purchases. The SA prepares a separate equipment purchase schedule for title XVIII non-LTC, title XVIII LTC and title XIX LTC equipment and prepares three separate Form CMS-1466s with its annual budget request. B. Heading The SA inserts official name of the agency, indicates which program and facility type (type XVIII LTC, XVIII non-LTC, or XIX LTC) and enters the name of the State in the designated space and the period for which equipment funds are requested. When equipment is actually purchased, the SA prepares a revised Form CMS-1466 with the next quarterly expenditure report. C. Column Entries 1. Column (A), Description of Equipment - The SA enters the items of equipment requested or reported as purchased. Note with an asterisk or other notation items previously approved by the RO, but which are being re-budgeted. On separate form, the SA explains why the purchase was not completed in the prior budget period. 2. Column (B), Number of Items on Hand - The SA lists the number of items on hand in the State survey unit as of the time the form is being prepared which are similar to the item requested. If a new and different item, enter zero (“0”) or leave blank in this column. 3. Columns (C) and (D), Number of Units (Additional) or (Replacement) - The SA lists the number of units in the appropriate column, (C) or (D). 4. Column (E), Unit Cost - The SA enters the unit cost for each item listed in column (A). 5. Column (F), Gross Cost - The automated system computes and enters the gross cost for each item in column (A) by multiplying the number of units in columns (C) or (D) by the unit cost, column (E). 6. Column (G), Trade-In Value If Replacement Item - The SA enters the trade-in value for any replacement item presented in column (A). 7. Column (H), Net Cost - Calculated value by subtracting column (G) from column (F). D. Total Net Cost of Equipment The automated system sums all amounts shown in column (H). The SA should enter this value on Form CMS-435, line 10, in the appropriate column. E. Certification: Date, Signature, and Title The automated system dates the Form CMS-1466. The SA certifying official enters their name and title.