Worksheet A-8-1

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MARWOOD MANOR NURSING HOME
PORT HURON, MI  48060

Medicare Provider Number: 235369
Cost report status: Settled Without Audit
[Record Code 1089793 - 2010]
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STATEMENT OF COSTS OF SERVICES
FROM RELATED ORGANIZATIONS AND
HOME OFFICE COSTS
 Provider CCN: 235369
PERIOD:
FROM 07/01/2014
TO 09/30/2014
 WORKSHEET A-8-1
 
PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS
  Line No. Cost Center Expense Items Amount Allowable In Cost Amount Included in Wkst. A., col. 5 Adjustments ( col. 4 minus col. 5 )  
1 2 3 4 5 6
1 ### ### ### ### ### 1
2 ### ### ### ### ### ### 2
3 ### ### ### ### ### 3
4 ### ### ### ### ### 4
5 ### ### ### ### ### 5
6 ### ### ### ### 6
7 ### ### ### ### 7
8 ### ### ### ### ### 8
9 ### ### ### ### ### 9
10 TOTALS (sum of lines 1-9) (Transfer column 6, line 10 to Wkst. A-8, col. 3, line 12) ### ### ### 10
 
PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND / OR HOME OFFICE
The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires that you furnish
the information requested under Part II of this worksheet.
This information is used by the Centers for Medicare and Medicaid Services and its intermediaries/contractors in determining that the costs applicable to
services, facilities, and supplies furnished by organizations related to you by common ownership or control represent reasonable costs as determined under
section 1861 of the Social Security Act. If you do not provide all or any part of the requested information, the cost report is considered incomplete and not
acceptable for purposes of claiming reimbursement under title XVIII.
  (1) Symbol Name Percentage of Ownership Related Organization(s)  
Name Percentage of Ownership Type of Business
1 2 3 4 5 6
1 ### ### ### ### ### ### 1
2 ### ### ### ### ### ### 2
3 ### ### ### ### ### ### 3
4 ### ### ### ### ### ### 4
5 ### ### ### ### ### ### 5
6 ### ### ### ### ### ### 6
7 ### ### ### ### ### ### 7
8 ### ### ### ### ### ### 8
9 9
10 10
(1) Use the followings symbols to indicate interrelationship to related organizations:
 
A. Individual has financial interest (stockholder, partner, etc.)
in both related organization and in provider.
B. Corporation, partnership or other organization has financial
interest in provider.
C. Provider has financial interest in corporation, partnership,
or other organization.
D. Director, officer, administrator or key person of provider or
organization.
E. Individual is director, officer, administrator or key person of provider
and related organization.
F. Director, officer, administrator or key person of related organization
or relative of such person has financial interest in provider.
G. Other (financial or non-financial) specify ______________________
_____________________________________________________
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4117)
Rev. 7   08-16