3490 (Cont.),,,Form CMS-265-94,,,,,,03-05
RECLASSIFICATIONS,,FACILITY NO.:,,,REPORTING PERIOD:,,WORKSHEET A-1,,
,,,,,FROM:___________________,,,,
,,_______________________,,,TO:____________________,,,,
,,CODE,                            INCREASE,,,                            DECREASE,,,
,,,COST,LINE,,COST,LINE,,
,EXPLANATION OF ENTRY,(1),CENTER,NO.,AMOUNT (2),CENTER,NO.,AMOUNT (2),
,,1,2,3,4,5,6,7,
   1,,,,,,,,,   1
   2,,,,,,,,,   2
   3,,,,,,,,,   3
   4,,,,,,,,,   4
   5,,,,,,,,,   5
   6,,,,,,,,,   6
   7,,,,,,,,,   7
   8 ,,,,,,,,,   8 
   9,,,,,,,,,   9
  10,,,,,,,,,  10
  11,,,,,,,,,  11
  12,,,,,,,,,  12
  13,,,,,,,,,  13
  14,,,,,,,,,  14
  15,,,,,,,,,  15
  16,,,,,,,,,  16
  17,,,,,,,,,  17
  18,,,,,,,,,  18
  19,,,,,,,,,  19
  20,,,,,,,,,  20
  21,,,,,,,,,  21
  22,,,,,,,,,  22
  23,,,,,,,,,  23
  24,,,,,,,,,  24
  25,,,,,,,,,  25
  26,,,,,,,,,  26
  27,,,,,,,,,  27
  28,,,,,,,,,  28
  29,,,,,,,,,  29
  30,,,,,,,,,  30
  31,,,,,,,,,  31
  32,,,,,,,,,  32
  33,,,,,,,,,  33
  34,,,,,,,,,  34
  35,,,,,,,,,  35
  36,TOTAL RECLASSIFICATIONS (Sum of Column 4,,,,,,,,  36
,must equal sum of Column 7),,,,,,,,
"(1)   A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.",,,,,,,,,
"(2)   Transfer to Worksheet A, Col 5, line as appropriate.",,,,,,,,,
"FORM CMS-265-94 (9-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3407)",,,,,,,,,
,,,,,,,,,
34-306,,,,,,,,,Rev. 7