AMBULANCE REVENUE and COST REPORT · AMBULANCE SERVICE ENTITY: FOR THE PERIOD FROM: PROFORMA TO:...

LONG REPORT - completed annually by: For-Profit Companies and Larger Ambulance Organizations

- completed by all applicants for a General Rate Increase

Legal Name of Company: CON No.

D.B.A. (Doing Business As): Business Phone:

Financial Records Address: City: Star Valley AZ Zip Code: 85541

Mailing Address (If Different): City: Zip Code:

Owner / Manager:

Report Contact Person: Business Phone: Ext.

Report for Period From: From: To:

Method of Valuing Inventory: LIFO: FIFO: X Other (Explain):

Please attach a list of all affiliated organizations (parents/subsidiaries) that exhibit at least 5% ownership/vesting.

I hereby verify that I have directed the preparation of the enclosed annual report in accordance with the reporting requirements of the State of Arizona.

I have read this report and hereby verify that the information provided is true and correct to the best of my knowledge.

This report has been prepared using the accrual basis of accounting.

Authorized Signature:

Title: Date:

Mail to:

Department of Health Services

Bureau of Emergency Medical Services

Certificate of Necessity and Rates Section

150 North 18th Avenue, Suite 540

Phoenix, AZ 85007-3248

Telephone: (602) 364-3150

Fax: (602) 364-3567

06/22/2004 Formula's Excluded

ACTUAL FINANCIAL DATA

Fire Chief

Proforma Proforma 12 Months

AMBULANCE REVENUE and COST REPORT

GENERAL INFORMATION and CERTIFICATION

Hellsgate Fire District

Rim Country Fire and Medical

928-474-3835

80 S, Walters Lane

Same

Fire Chief David Bathke

David Bathke

AMBULANCE SERVICE ENTITY:

FOR THE PERIOD FROM: PROFORMA TO:

STATISTICAL SUPPORT DATA(1) (2)** (3) (4)

SUBSCRIPTION TRANSPORTS TRANSPORTS

SERVICE UNDER NOT UNDER

Line TRANSPORTS CONTRACT CONTRACT TOTALS

No. DESCRIPTION

1 Number of ALS Billable Transports: 2,400 2,400

2 Number of BLS Billable Transports: 600 600

3 Number of Loaded Billable Miles: 60,000 60,000

4 Waiting Time (Hr. & Min.): - 0

5 Canceled (Non-Billable) Runs: 320 320

Number

Donated

Volunteer Services: (OPTIONAL) Hours

6 Paramedic and IEMT ……………………………………………….

7 Emergency Medical Technician - B ……………………………………………….

8 Other Ambulance Attendants ……………………………………………….

9 Total Volunteer Hours ………………………………………………. 0

** This column reports only those runs where a contracted discount rate was applied. See Page 7 to provide additional information regarding discounted

contract runs.

Page 1

AMBULANCE REVENUE AND COST REPORT

Rim Country Fire and Medical

Proforma 12 Months


FOR THE PERIOD FROM: Proforma TO:

STATISTICAL SUPPORT DATA

(1) (2) (3)

NON-Line SUBSIDIZED SUBSIDIZED

No. Type of Service PATIENTS PATIENTS TOTALS

1 Number of ALS Billable Transports: 2,400 2,400

2 Number of BLS Billable Transports: 600 600

3 Number of Loaded Billable Miles: 60,000 60,000

4 Waiting Time (Hr. & Min.): - 0

5 Canceled (Non-Billable) Runs: 320 320

Number

Donated

Volunteer Services: (OPTIONAL) Hours

6 Paramedic and IEMT ……………………………………….

7 Emergency Medical Technician - B ……………………………………….

8 Other Ambulance Attendants ……………………………………….

9 Total Volunteer Hours ………………………………………. 0

Note: This page and page 3.1, Routine Operating Revenue, are only for those governmental agencies that apply subsidy to patient billings.

Page 1.1


Proforma 12 Months


FOR THE PERIOD FROM: PROFORMA TO: Proforma 12 Months

STATEMENT OF INCOME

Line

No. DESCRIPTION FROM

Operating Revenues:

1 Ambulance Service Routine Operating Revenue ….. Page 3, Line 10 & Page 3.1, Line 10 ……………………………………….. $ 5,987,250

Less:

2 AHCCCS Settlement …………… Page 3.1, Line 11 ………………………………. 478,980

3 Medicare Settlement …………… Page 3.1, Line 12 ………………………………. 2,155,410

4 Contractual Discounts …………… Page 7, Line 22 ………………………………. 0

5 Subscription Service Settlement …………… Page 8, Line 4 ………………………………. 0

6 Other (Attach Schedule) …………… Page 3.1, Line 13 ………………………………. 0

7 Total ……………………………………………………………… Sum of Lines 2 through 6 ……………………… 2,634,390

8 Net Revenue from Ambulance Runs ……………………………… Line 1, minus Line 7 …………………… 3,352,860

9 Sales of Subscription Service Contracts ………… Page 8, Line 8 ………………………………………… 0

10 Total Operating Revenue ………………………………………. Line 8, plus Line 9 ……………………………… $ 3,352,860

Ambulance Operating Expenses:

11 Bad Debt (Includes Subscription Services Bad Debt) …… …………………………………..………………..………………….. 419,108

12 W ages, Payroll Taxes, and Employee Benefits …. Page 4, Line 22 ………………. 1,720,318

13 General and Administrative Expenses ………………….. Page 5, Line 20 …………………… 312,280

14 Cost of Goods Sold …………………………………………………..Page 3, Line 15 ………………………….. 106,000

15 Other Operating Expense …………………………………………….Page 6, Line 28 ………………………………….. 764,758

16 Interest Expense (Attach Schedule IV) ………………………. Page 14, Line 28, Column 4 & 5 ……………. 0

17 Subscription Service Direct Selling ……………………………….Page 8, Line 23 …………………………………………... 0

18 Total Operating Expense …………………………. Sum of Lines 11 through 17 ……………………………….. 3,322,463

19 Ambulance Service Income (Loss) ……………………………… Line 10, minus Line 18 ……………………………….. 30,397

Other Revenue / Expenses:20 Other Operating Revenue and Expense …….. Page 9, Line 17 ………………………… 0

21 Non-Operating Revenue and Expense ……………… ………………………… 0

22 Non-Deductible Expenses (Attach Schedule) …………….. ………………………… 0

23 Total Other Revenues / Expenses ………………………………. Sum of Lines 20 & 21 ……………………… 0

24 Ambulance Service Income (Loss) - Before Income Taxes ……. Sum of Line 19, plus Line 23 ……………………….. 30,397

Provision for Income Taxes:25 Federal Income Tax ……………………………………….……………………………………….

26 State Income Tax ……………………………………….……………………………………….

27 Total Income Tax ………………………… Lines 25, plus Line 26 ……………………….. 0

28 Ambulance Service Net Income (Loss) ………………. Line 24, minus Line 27 ……………………….. 30,397

Page 2


RIM COUNTRY FIRE AND MEDICAL



ROUTINE OPERATING REVENUE

Line

No. DESCRIPTION

Ambulance Service Routine Operating Revenue:

1 ALS Base Rate Amount Rate $ 1,500.15 x No. of Runs 2,400 = $ 3,600,360$ Rate x No. of Runs = -$

2 BLS Base Rate Amount Rate 1,500.15 x No. of Runs 600 = 900,090$ Rate x No. of Runs = -$

3 Mileage Rate Amount Rate 22.33 x No. of Billable Miles 60,000 = 1,339,800$ Rate x No. of Billable Miles = -$

4 Waiting Charge Amount Rate 115.40 x No. of Hours - = -$ Rate x No. of Hours = -$

5 Medical Supplies (Gross Charges to patients) …………………………………………………………….. 147,000$

6 Nurses Charges ……………………………………………………………………..

7 Total ………………………………………………………………………………… 5,987,250$

8 Standby Revenue (Attach Schedule) …………………………………………………………………………………………..

9 Other Ambulance Service Revenue (Attach Schedule) ………………………………………………………………………………………………

10 Total Ambulance Service Routine Operating Revenue (To Page 2, Line 1) ……………………………. $ 5,987,250$

Cost of Goods Sold: (Medical Supplies)

11 Inventory at Beginning of Year ……………………….. 012 Plus Purchases ……………………………… 146,00013 Plus Other Costs ………………………………………14 Less Inventory at End of Year ………………………………………………. 40,000

15 Cost of Goods Sold (To Page 2, Line 14) $ 106,000

Page 3





ROUTINE OPERATING REVENUE Identified by subsidized and non-subsidized patients

(1) (2) (3)

NON-

Line SUBSIDIZED SUBSIDIZED

No. DESCRIPTION PATIENTS PATIENTS TOTALS

AMBULANCE SERVICE OPERATING REVENUE

1 ALS Base Rate ……………….. $ $ 3,600,360 $ 3,600,360

2 BLS Base Rate …………………… 900,090 900,090

3 Mileage Charge ………………………… 1,339,800 1,339,800

4 Waiting Charge …………………………………… 0 0

5 Medical Supplies ………….. (Gross Charges) …. 147,000

6 Nurses' Charges ………………… 0

7 Total $ $ $ 5,987,250

Plus:

8 Standby Revenue ………….. (Attach Schedule) …………………………………….

9 Other Ambulance Service Revenue (Attach Schedule) ……………………………………………………….

10 Total Ambulance Service Routine Operating Revenue (Post to Pg 2, Line 1) ………………. $ 5,987,250

Less:

11 AHCCCS Settlement (Post total to Pg 2, Line 2) $ $ 478,980 $ 478,980

12 Medicare Settlement (Post total to Pg 2, Line 3) 2,155,410 2,155,410

13 Subsidy (Post total to Pg 2, Line 6)

14 Other (Attach Schedule)

15 Total Settlements (Post to Pg 2, Line 7) $ 0 $ 2,634,390 $ 2,634,390

Note: This page and page 1.1, are only for those governmental agencies that apply subsidy to patient billings.

Page 3.1





WAGES, PAYROLL TAXES, and EMPLOYEE BENEFITS

Line No. of

No. DESCRIPTION *F.T.E. AMOUNT

OFFICERS / OWNERS (Attach Schedule 1, Wage Category; Pg 10, Line 7)

1 Gross Wages ……………………………………………. $

2 Payroll Taxes …………………………………………………………

3 Employee Fringe Benefits ……………………………………………………………………..

4 Total ……………………………………………………………………………………….. 0.0 0

MANAGEMENT (Attach Schedule II, Wage Detail; Pg 11)

5 Gross Wages ……………………………………………. 2.0 183,526

6 Payroll Taxes ………………………………………………………… 3,634

7 Employee Fringe Benefits …………………………………………………………………….. 49,552

8 Total ……………………………………………………………………………………….. 2.0 236,712

AMBULANCE PERSONNEL (Attach Schedule II, Wage Detail; Pg 11) ** Casual Wages

Gross Wages Labor

9 Paramedics and IEMT ………………….. $ $ 17.0 607,131

10 Emergency Medical Technician (EMT) …………………………. 17.0 543,130

11 Nurses ……………………………………..

12 Payroll Taxes ……………………………………………………. 22,775

13 Employee Fringe Benefits ………………………………………………………………………. 310,570

14 Total ……………………………………………………………………………………… 34.0 1,483,606

OTHER PERSONNEL (Attach Schedule II, Wage Detail; Pg 11)

Gross Wages

15 Dispatch …………………..

16 Mechanics ………………………….

17 Office and Clerical ……………………………………..

18 Other …………………………………………………….

19 Payroll Taxes …………………………………………………………………

20 Employee Fringe Benefits ………………………………………………………………………………

21 Total ……………………………………………………………………………………… 0.0 0

22 Total F.T.E., Wages, Payroll Taxes, & Employee Benefits (Post to Pg 2, line 12) ….. 36.0 $ 1,720,318

* Full-time equivalents (F.T.E.) is the sum of all hours for which employee wages were paid during the year divided by 2,080.

** The sum of Casual Labor (wages paid on a per run basis) plus Wages paid is entered in Column 2 by line item. However

when calculating F.T.E.s, do not include casual labor hours worked or expenses incurred.

Page 4





ALLOCATION OF WAGES, PAYROLL TAXES, and EMPLOYEE BENEFITS

(1) (2) (3) (4)

Line No. of Total Allocation Ambulance

No. DESCRIPTION *F.T.E. Expenditure Percentage Amount

MANAGEMENT

1 Gross Wages (Attach Schedule II) 2 183,526 100% 183,526

2 Payroll Taxes 3,634 100% 3,634

3 Employee Fringe Benefits 49,552 100% 49,552

4 Total 2 236,712 236,712

AMBULANCE PERSONNEL ** Contractual Wages

Gross Wages (Attach Schedule II) Labor

5 Paramedics and IEMT $ 17.17 17 607,131 100% 607,131

6 Emergency Medical Technician (EMT) 15.36 17 543,130 100% 543,130

7 Nurses 0

8 Drivers 100% 0

9 Payroll Taxes 22,775 100% 22,775

10 Employee Fringe Benefits 310,570 100% 310,570

11 Total 34 1,483,606 1,483,606

OTHER PERSONNEL

Gross Wages (Attach Schedule II)

12 Dispatch

13 Mechanics

14 Office and Clerical

15 Other

16 Payroll Taxes

17 Employee Fringe Benefits

18 Total 0 0 0

19 TOTAL F.T.E., WAGES, PAYROLL (Post to Pg 2, line 12) 36 1,483,606 $ 1,483,606

TAXES & EMPLOYEE BENEFITS

* Full-time equivalents (F.T.E.) is the sum of all hours for which employee wages were paid during the year divided by 2,080.

** The sum of Casual Labor (wages paid on a per run basis) plus Wages paid is entered in Column 2 by line item. However, when calculating F.T.E's, do not include casual labor hours

worked or expenses incurred.

Page 4.1





BASIS OF ALLOCATIONS OF WAGES, PAYROLL et al.

Line

No. DESCRIPTION

1 Gross Wages - MANAGEMENT

2 Payroll Taxes


4 Total

Contractual Wages

Gross Wages - AMBULANCE PERSONNEL

5 Paramedics and IEMT 100 percent ambulance operations

6 Emergency Medical Technician (EMT) 100 percent ambulance operations

7 Nurses 100 percent ambulance operations

8 Drivers 100 percent ambulance operations

9 Payroll Taxes 100 percent ambulance operations

10 Employee Fringe Benefits 100 percent ambulance operations

11 Total 100 percent ambulance operations

Gross Wages - OTHER PERSONNEL

12 Dispatch

13 Mechanics

14 Office and Clerical

15 Other

16 Payroll Taxes


18 Total

Page 4.1.a

100 percent ambulance operations












Basis of Allocations




GENERAL and ADMINISTRATIVE EXPENSES

Line

No. DESCRIPTION

Professional Service:

1 Legal Fees ……………………… $ 12,000

2 Collection Fees ………………………………… 205,363

3 Accounting and Auditing …………………………………………. 4,000

4 Data Processing Fees ………………………………………………… 0

5 Other (Attach Schedule) …………………………………………………………. 0

6 Total …………………………………………………………………………. $ 221,363

Travel and Entertainment:

7 Meals and Entertainment ……………………… 1,100

8 Transportation - Other Company Vehicles ………………………………… 0

9 Travel …………………………………………. 8,740

10 Other (Attach Schedule) ………………………………………………… 0

11 Total ……………………………………………………………………………. 9,840

Other General and Administrative:

12 Office Supplies ……………… 7,200

13 Postage …………………… 825

14 Telephone …………………………… 22,560

15 Advertising …………………………………… 8,000

16 Professional Liability Insurance …………………………………………… 37,492

17 Dues and Subscriptions …………………………………………………… 5,000

18 Other (Attach Schedule) ………………………………………………………… 0

19 Total …………………………………………………………………………… 81,077

20 Total General and Administrative Expenses (Post to Page 2, Line 13) …………………………………………….. $ 312,280

Page 5





ALLOCATION of GENERAL and ADMINISTRATIVE EXPENSES

(1) (2) (3)

Line Total Allocation Ambulance

No. DESCRIPTION Expenditure Percentage Amount


1 Legal Fees ……………. $ 12,000 100% $ 12,000

2 Collection Fees …………………. 205,363 100% 205,363

3 Accounting and Auditing ………………………… 4,000 100% 4,000

4 Data Processing Fees ……………………………… 0

5 Other (Attach Schedule) ………………………………………. 0

6 Total …………………………………………………. 221,363 221,363


7 Meals and Entertainment ……………. 1,100 100% 1,100

8 Transportation - Other Company Vehicles ………………….

9 Travel ………………………… 8,740 100% 8,740

10 Other (Attach Schedule) ………………………………

11 Total …………………………………………………. 9,840 9,840


12 Office Supplies ……………. 7,200 100% 7,200

13 Postage …………………. 825 100% 825

14 Telephone ………………………… 22,560 100% 22,560

15 Advertising ……………………………… 8,000 100% 8,000

16 Professional Liability Insurance …………………………………… 37,492 100% 37,492

17 Dues and Subscriptions ………………………………………. 5,000 100% 5,000

18 Other (Attach Schedule) ……………………………………………

19 Total ………………………………………………… 81,077 81,077

20 Total General and Administrative Expenses (Post to Page 2, Line 13) $ 312,280 312,280

Page 5.1


IM COUNTRY FIRE AND MEDICAL



BASIS of ALLOCATION OF GENERAL and ADMINISTRATIVE EXPENSES

Line

No. DESCRIPTION


1 Legal Fees

2 Collection Fees

3 Accounting and Auditing

4 Data Processing Fees


6 Total


7 Meals and Entertainment

8 Transportation - Other Company Vehicles

9 Travel


11 Total


12 Office Supplies

13 Postage

14 Telephone

15 Advertising

16 Professional Liability Insurance

17 Dues and Subscriptions


19 Total

Page 5.1.a



Basis of Allocation




















OTHER OPERATING EXPENSES

Line

No. DESCRIPTION

Depreciation and Amortization:

1 Depreciation (Attach Schedule III) ….. (From Pg 13, Line 20, Col I) …….. $ 36,318

2 Amortization ……………………………………… 0

3 Total ……………………………………………………………………………………………………………………$ 36,318

4 Rent / Lease (Attach Schedule III) (From Pg 13, Line 20, Col K) ……………………………………………… 209,500

Building / Station Expense:

5 Building and Cleaning Supplies …………. 3,250

6 Utilities ……………… 5,150

7 Property Taxes ……………………. 0

8 Property Insurance …………………………… 0

9 Repairs and Maintenance …………………………………. 6,000

10 Other (Attach Schedule) …………………………………………. 0

11 Total ………………………………………………………………………… 14,400

Vehicle Expense - Ambulance Units:

12 License / Registration …………. 2,806

13 Fuel ……………… 31,000

14 General Vehicle Service and Maintenance ……………………. 48,000

15 Vehical Lease/Purchase …………………………… 10,000

16 Insurance - Service Vehicles …………………………………. 0

17 Other (Attach Schedule) …………………………………………. 0

18 Total …………………………………………………………………………… 91,806

Other Expenses:

19 Dispatch …………. 249,000

20 Education / Training ……………… 28,000

21 Uniforms and Uniform Cleaning ……………………. 6,839

22 Meals and Travel for Ambulance personnel …………………………… 0

23 Maintenance Contracts …………………………………. 12,000

24 Minor Equipment - Not Capitalized ……………………………………… 16,895

25 Ambulance Supplies - Nonchargeable …………………………………………. 100,000

26 Other (Attach Schedule) …………………………………………… 0

27 Total …………………………………………………………… 412,734

28 Total Other Operating Expenses …… (Post to Page 2, Line 15) …………………………… $ 764,758

Page 6





ALLOCATION of OTHER OPERATING EXPENSES

(1) (2) (3)

Line Total Allocation Ambulance

No. DESCRIPTION Expenditure Percentage Amount


1 Depreciation (Attach Schedule III) ……………….. (From Pg 13, Line 20, Col I) … … $ 36,318 100% $ 36,318

2 Amortization ………………….. 0

3 Total ……………………………. 36,318 36,318

4 Rent / Lease (Attach Schedule III) (From Pg 13, Line 20, Col K) …… 209,500 100% 209,500


5 Building and Cleaning Supplies ………. 13,000 25% 3,250

6 Utilities …………. 20,600 25% 5,150

7 Property Taxes ……………. 0

8 Property Insurance ……………….. 0

9 Repairs and Maintenance ……………………… 24,000 25% 6,000

10 Other (Attach Schedule) …………………………… 0

11 Total ……………………………….. 57,600 14,400


12 License / Registration ………. 2,806 100% 2,806

13 Fuel …………. 31,000 100% 31,000

14 General Vehicle Service and Maintenance ……………. 48,000 100% 48,000

15 Major Repairs ……………….. 10,000 100% 10,000

16 Insurance - Service Vehicles ……………………… 0

17 Other (Attach Schedule) …………………………… 0

18 Total ……………………………….. 91,806 91,806

Other Expenses:

19 Dispatch ………. 249,000 100% 249,000

20 Education / Training …………. 28,000 100% 28,000

21 Uniforms and Uniform Cleaning ……………. 6,839 100% 6,839

22 Meals and Travel - Ambulance Personnel ……………….. 100% 0

23 Maintenance Contracts ……………………… 12,000 100% 12,000

24 Minor Equipment - Not Capitalized …………………………… 16,895 100% 16,895

25 Ambulance Supplies - Nonchargeable ……………………………….. 100,000 100% 100,000

26 Other (Attach Schedule) ………………………………….. 0

27 Total ……………………………………….. 412,734 412,734

28 Total Other Operating Expenses ………… (Post to Page 2, Line 15) .. $ 807,958 $ 764,758

Page 6.1





BASIS of ALLOCATION OF OTHER EXPENSES

Line

No. DESCRIPTION


1 Depreciation

2 Amortization

3 Total

4 Rent / Lease


5 Building and Cleaning Supplies 25 percent ambulance operations

6 Utilities 25 percent ambulance operations

7 Property Taxes 25 percent ambulance operations

8 Property Insurance 25 percent ambulance operations

9 Repairs and Maintenance 25 percent ambulance operations

10 Other 25 percent ambulance operations

11 Total 25 percent ambulance operations


12 License / Registration

13 Fuel

14 General Vehicle Service and Maintenance

15 Major Repairs

16 Insurance - Service Vehicles

17 Other

18 Total

Other Expenses:

19 Dispatch

20 Education / Training

21 Uniforms and Uniform Cleaning

22 Meals and Travel for Ambulance personnel

23 Maintenance Contracts

24 Minor Equipment - Not Capitalized

25 Ambulance Supplies - Nonchargeable


27 Total

Page 6.1.a



Basis of Allocation























DETAIL OF CONTRACTUAL ALLOWANCES

Total

Line Billable Gross Percent

No. Name of Contracting Entity Runs Billing Discount Allowance

1 NOT APPLICABLE N/A N/A N/A N/A

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22 (Post Total to Page 2, Line 4) -$

Page 7





SUBSCRIPTION SERVICE REVENUE AND

DIRECT SELLING EXPENSES

Line

No. Description

1 Billings at Fully Established Rate …………………………………………………………………………………. $

Less:

2 AHCCCS Settlement ……………………………………………………………………………………………………………………..$

3 Medicare Settlement ……………………………………………………………

4 Subscription Service Settlement …………………………………………………..(Post to Pg 2, Line 5) …

5 Subscription Service Bad Debt …………………………………………………………

6 Total ……………………………………………………………………………………………………………………………………… 0

Plus:

7 Net Revenue from Subscription Service Runs …………………………………………………………………………………

8 Sales of Subscription Service ……………………………………………………..(Post to Pg 2, Line 9) ………………………

9 Other Revenue …………………………………………………………………………………..(attach schedule) ……………………

10 Total Subscription Service Revenue ………………………………………………………………………………………….(total of Lines 7, 8 and 9) 0

Direct Expenses Incurred Selling Subscription Contracts

11 Salaries / Wages ………………………………………………………………………

12 Payroll Taxes …………………………………………………………………………

13 Employee Fringe Benefits …………………………………………………………………

14 Professional Services ……………………………………………………………………………

15 Contract Labor ……………………………………………………………………………

16 Travel ………………………………………………………………………………………

17 Other General & Administrative Expenses …………………………………………………

18 Depreciation / Amortization ……………………………………………………………………

19 Rent / Lease ……………………………………………………………………………………

20 Building / Station Expense …………………………………………………………………

21 Transportation / Vehicles ………………………………………………………………

22 Other: (attach schedule) ……

23 Total Subscription Service Expenses ………………………………………..(Post to Pg 2, Line 17) …………………………… $ 0

Page 8





OTHER OPERATING REVENUES & EXPENSES

Line

No. Description

Other Operating Revenues:

1 Supportive Funding - Local (attach schedule) ………………… $

2 Grant Funds - State (attach schedule) …………………

3 Grant Funds - Federal (attach schedule) …………………

4 Grant Funds - Other (attach schedule) …………………

5 Monthly repeater charge 0

6 Patient Late Payment Charges ……………………………………………………

7 Interest Earned - Related Person / Organization …………………………………

8 Interest Earned - Other ……………………………………………………………….

9 Gain on Sale of Operating Property ………………………………………………….

10 Other: ………………………………

11 Other: ………………………………

12 Total Other Operating Revenues …………………………………………………………………………. $ 0

Other Operating Expenses:

13 Loss on Sale of Operating Property ……………………………………

14 Other: ………………………………

15 Other: …………………………………………

16 Total Other Operating Expenses …………………………………………………………………………… 0

17 Net Other Operating Revenues and Expenses ……………………(Post to Pg 2, Line 20) ……….. $ 0

Page 9



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No. Detail of Salaries / Wages - Other Than Officers / Owners

1 MANAGEMENT:

Certification Scheduled Shifts Hourly Annual $ Per Run

and / or Title ( no. of hours worked each week) Wage Salary or Shift

Manager 44.12$ 91,769.60$

2 AMBULANCE PERSONNEL:

Paramedic 17.17$ 35,713.60$

EMT 15.36$ 31,948.80$

3 OTHER PERSONNEL:

Page 11

DETAIL of SALARIES / WAGES

Management, Ambulance Personnel, Other Personnel



Schedule II

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FOR THE PERIOD FROM: PROFORMA TO: PROFORMA 12 MONTHS

(1) (2) (3) (4) (5)

Line Interest Beginning of End of Related Persons or

No. Description Rate Period Period Organizations Other

Service Vehicles & Accessorial Equipment

Name of Payee:

1 % $ $ $ $

2

3

4

Communication Equipment

Name of Payee:

5

6

7

Other Property and Equipment

Name of Payee:

8

9

10

W orking Capital

Name of Payee:

11

12

13

Other

Name of Payee:

14 %

15 TOTAL $ 0 $ 0 $ 0 $ 0

Post totals of Column 4 & 5 to Pg 2, Line 16

Page 14


DETAIL OF INTEREST

Principal Balance Interest Expense


Schedule IV



BALANCE SHEET

ASSETSStart of Operations + 12 months

CURRENT ASSETS

1 Cash ……………… $ 458,571

2 Accounts Receivable ………………….. 588,574

3 Less: Allowance for Doubtful Accounts ………………………

4 Inventory ……………………………….

5 Prepaid Expenses …………………………………….

6 Other Current Assets ………………………………………………..

7 TOTAL CURRENT ASSETS …………………………………………………………….. $ 1,047,145

9 PROPERTY & EQUIPMENT …………………………………………………………………….. 181,590

10 Less: Accumulated Depreciation ………………………………………………………………………………. -36,318

11 OTHER NON CURRENT ASSETS ……………………………………………………………………………………….

12 TOTAL ASSETS ……………………………………………………………………………………………… $ 1,192,417

LIABILITIES & EQUITY

CURRENT LIABILITIES

13 Accounts Payable ……………… $ 22,481

14 Current Portion of Notes Payable ………………….

15 Current Portion of Long-Term Debt ………………………. 50,000

16 Deferred Subscription Income ………………………………

17 Accrued Expenses and Other ……………………………………. 59,609

18 …………………………………………… 59,115

19 ……………………………………………….

20 TOTAL CURRENT LIABILITIES ………………………………………………………………… $ 191,205

21 NOTES PAYABLE ………………………..

22 LONG-TERM DEBT OTHER ……………………………….. 200,000

23 TOTAL LONG-TERM DEBT …………………………………………………………….. 200,000

EQUITY & OTHER CREDITSPaid-In Capital:

24 Common Stock ……………….

25 Paid-In Capital in Excess of Par Value ……………………..

26 Contributed Capital ……………………………

27 Retained Earnings ………………………………….

28 ……………………………………….

29 ……………………………………………. 30,397

30 Fund Balance …………………………………………………. 770,815

31 TOTAL EQUITY ………………………………………………………… 801,212

32 TOTAL LIABILITIES & EQUITY ………………………………………………………………….. $ 1,192,417

Page 15

Enterprise Net Income





STATEMENT OF CASH FLOWS

OPERATING ACTIVITIES:1 Net (loss) Income ………………………………….. $ 30,397

Adjustments to Reconcile Net Income to Net Cash

Provided by Operating Activities: Note: a increase in these accounts improves cash flow

2 Depreciation Expense …………………………………………… 36,318

3 Deferred Income Tax ………………………………………………….

4 Loss (gain) on Disposal of Property & Equipment ……………………

(Increase) Decrease in: Note: a decrease in these accounts improves cash flow

5 Accounts Receivable …………………… -482,261 60 Days New AR

6 Inventories …………………………

7 Prepaid Expenses ……………………………….

Increase (Decrease) in: Note: a increase in these accounts improves cash flow

8 Accounts Payable …………………………………….

9 Accrued Expenses …………………………………………..

10 Deferred Subscription Income ……………………………………………………

11 NET CASH PROVIDED (Used) BY OPERATING ACTIVITIES $ -415,546

INVESTING ACTIVITIES:12 Purchases of Property & Equipment …………………………. -181,590

13 Proceeds from Disposal of Property & Equipment ………………….

14 Purchases of Investments ……………………………………

15 Proceeds from Disposal of Investments …………………………………………..

16 Loans Made ……………………………………………….

17 Collections on Loans ……………………………………………………..

18 Other ……………………………………………………………

19 NET CASH PROVIDED (Used) BY INVESTING ACTIVITIES ……………………………………………… -181,590

FINANCING ACTIVITIES:New Borrowings:

20 Long-Term ………………………………….. 250,000

21 Short-Term ……………………………………………

Debt Reduction:

22 Long-Term …………………………………..

23 Short-Term ……………………………………………

24 Capital Contributions ………………………………………………….

25 Dividends Paid ………………………………………………………… $

26 NET CASH PROVIDED (Used) BY FINANCING ACTIVITIES ……………………. 250,000

27 NET INCREASE (Decrease) IN CASH ………………………………………………………….. -347,136

28 CASH AT BEGINNING OF YEAR …………………………………………………………………. 805,707

29 CASH AT END OF YEAR ……………………………………………………………………….. 458,571

SUPPLEMENTAL DISCLOSURES:Non-cash Investing and Financing Transactions:

30 ………………………

31 ………………………….

32 ……………………………….

33 Interest Paid (Net of Amounts Capitalized) ………………………………………

34 Income Taxes Paid …………………………………………… $

Page 16



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