Disclosure - Login

EO-38 Covered Provider Determination Worksheet

Provider Name
Covered Reporting Period From   To 
Prepared By
Title
Affiliation of Preparer (i.e. employee, board member, contractor, etc.)
Please provide Company Name, Relationship to the company if different from Provider
Company Name(Optional)   Relationship to Company(Optional)  
NOTES
Please review the guidance, regulations, definitions and terminology before completing this form.
Enter all dollar values as whole numbers.
The method of accounting used by the individual/entity in producing the annual financial reports shall be used in all EO-38 calculations.
Individuals/entities must keep all supporting documentation used for the Determination (including, but not limited to, any of the recommended EO-38 Worksheets used in the process) and must be able to provide that documentation upon request.
Date Prepared : Fri Jun 23 16:35:15 EDT 2017
Print Determination Worksheet

A.INITIAL EXEMPTION
1.Is the individual/entity a State, County or local governmental unit, a tribal nation, or subdivision/subsidiary thereof? Yes No  

B. REPORTING PERIODS
2.What is the Covered Reporting Period(CRP)?
2a.What is the Reporting Period for the one-year period immediately preceding the Covered Reporting Period(CRP)?      

C. PROGRAM SERVICES
3.Did the individual/entity provide Program Services during the CRP? Yes No  

STATE FUNDS/STATE AUTHORIZED PAYMENTS(SF/SAP) - To complete the remainder of the worksheet, the SF/SAP must first be calculated for the CRP and the year prior. Proceed to the guidance and the associated SF/SAP Calculation Worksheet. When finished, return to complete this form using the SF/SAP calculations.


D. ADDITIONAL EXEMPTIONS
4.Did the individual/entity qualify for any of the following exemptions during the CRP:
a.The individual/entity is an individual professional, partnership or S-Corporation that meets certain thresholds. Yes No  
b.The individual/entity provides primarily or exclusively products rather than services using SF/SAP. Yes No  
c.All of the SF/SAP received by the individual/entity are derived from certain child care subsidies. Yes No  
d.The individual/entity received SF/SAP exclusively from/through a state agency that has promulgated a specific exemption from "covered provider status" that is applicable to the organization. Yes No  

E. STATE FUNDS/STATE AUTHORIZED PAYMENTS(SF/SAP) RECEIVED
5.What is the total amount of SF/SAP received from all sources during the CRP? $  
6.What is the total amount of SF/SAP received from all sources during the one-year period immediately preceding the CRP? $  
6a.Average of lines 5 and 6.   $      

F. TOTAL IN-STATE REVENUES
7.What is the total amount of "in state" revenues received during the CRP? $      
8.What is the total amount of "in state" revenues received during the one-year period immediately preceding to the CRP? $      
9.SF/SAP as a percent of "in-state" revenues received in the CRP.   %   
10.SF/SAP as a percent of "in-state" revenues received during the one-year period immediately preceding the CRP.   %