12-05,,,,Form CMS-265-94,,,,,3490 (Cont.)
PART 1. STATEMENT OF TOTAL COMPENSATION TO,,,,FACILITY NO.:,,REPORTING PERIOD:,,WORKSHEET A-4,
              OWNERS. (INCLUDE COMPENSATION OF,,,,,,FROM_______________,,,
              EMPLOYEES RELATED TO OWNER),,,,,,,,,
,,,,___________________,,TO_______________,,,
,,,SOLE PRO-,,,       CORPORATION ,,,
,TITLE,FUNCTION,PRIETOR-,           PARTNERS,,             OWNERS,,,
,,(A),SHIPS,,,,,            TOTAL,
,,,PERCENTAGE,,PERCENTAGE,,PERCENTAGE,COMPENSATION,
,,,OF,PERCENT,OF,PERCENT,OF,      INCLUDED IN,
,,,CUSTOMARY,SHARE OF,CUSTOMARY,OF,CUSTOMARY,      ALLOWABLE ,
,,,WORK WEEK,OPERATING,WORK WEEK,PROVIDER'S,WORK WEEK,      COSTS FOR,
,,,DEVOTED TO,PROFIT,DEVOTED TO,STOCK,DEVOTED TO,     THE PERIOD,
,,,BUSINESS,OR(LOSS),BUSINESS,OWNED,BUSINESS,             (B),
,(1),(2),(3),(4a),(4b),(5a),(5b),(6),
1,,,,,,,,,1
2,,,,,,,,,2
3,,,,,,,,,3
4,,,,,,,,,4
5,,,,,,,,,5
6,,,,,,,,,6
7,,,,,,,,,7
8,,,,,,,,,8
9,,,,,,,,,9
10,,,,,,,,,10
,,,,,,,,,
(A) Fully describe function or job description of each owner on reverse side of this page or a separate page,,,,,,,,,
,"(If employee is related to owner, site relationship.)",,,,,,,,
(B) Compensation as used in this worksheet has the same definition as CFR 413.102,,,,,,,,,
,,,,,,,,,
"PART II. STATEMENT OF TOTAL COMPENSATION TO ADMINISTRATORS, ASSISTANT ADMINISTRATORS",,,,,,,,,
              AND/OR MEDICAL DIRECTORS OR OTHERS PERFORMING THESE DUTIES(OTHER THAN OWNERS),,,,,,,,,
,,,TO BE COMPLETED BY ALL FACILITIES,,,,,,
,,,,     PERCENTAGE OF CUSTOMARY,,,,,
,,,,               WORK WEEK DEVOTED,,,   TOTAL COMPENSATION,,
,,TITLE,,                       TO BUSINESS,,,         FOR THE PERIOD,,
1,,,,,,,,,1
2,,,,,,,,,2
3,,,,,,,,,3
4,,,,,,,,,4
5,,,,,,,,,5
6,,,,,,,,,6
7,,,,,,,,,7
8,,,,,,,,,8
9,,,,,,,,,9
10,,,,,,,,,10
,,,,,,,,,
"FORM CMS-265-94 (9/94) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3410)",,,,,,,,,
,,,,,,,,,
Rev. 9,,,,,,,,,34-309