Preparation of State Survey Agency Budget Request - Long-

4626 - Preparation of State Survey Agency Budget Request - Long- Term Care, Form CMS-435 (Exhibit 45) (Rev. 1, 05-21-04) A. Usage - Form CMS-435 is a multi-purpose, multi-program form. The SA can include its budget requests for title XVIII LTC and non-LTC, as well as title XIX LTC, on one Form CMS-435. B. Heading - Automated system inserts the official name of the State agency, enters the appropriate Region and State Code. The SA enters the FY for which funds are requested. C. Rounding To Next Higher Dollar - In preparing Form CMS-435, the automated system rounds dollar amounts of funds requested for each line item to the next higher dollar. D. Salaries - Secure totals for professional and clerical staff-years, and money amounts from the accompanying Form CMS-1465A. Place totals in appropriate columns. Separate reporting is required for title XVIII LTC and title XIX positions. The funds requested to support activities carried out under title XVIII, title XIX and the State are to be based on the proration of staff time determined to be supportable by Medicare, Medicaid, and the State as negotiated with the CMS-RO. (See §4514.) E. Other Direct Costs - Enters estimates for these categories as developed in the narrative justification. (See §4611.) F. Total Direct Costs - Automated system adds lines 3 and l5 of the appropriate column. G. Indirect Costs - Enters the rate and the base against which the rate is charged. (See §4611.) Expenditures included in this category must not be duplicated under direct costs. H. Total Budget Request - Automated system totals lines 16 and 17 and enters the Total Costs in Line 19. I. Certification: Date, Signature, and Title - The automated system enters the date for budget request. In the signature space, the SA’s certifying official types their name and title.