12-99			      FORM CMS-2552-96							    3690 (Cont.)					
RECONCILIATION OF CAPITAL COSTS CENTERS					PROVIDER NO.:		PERIOD:		"WORKSHEET A-7,"						
							FROM _________		PARTS III & IV						
					 _____________		TO __________								
PART III - RECONCILIATION OF CAPITAL COSTS CENTERS															
			    COMPUTATION OF RATIOS				ALLOCATION OF OTHER CAPITAL								
				Gross Assets					Total						
			Capitalized	for Ratio	Ratio			Other Capital-	(sum of						
	Description	Gross Assets	Leases	(col. 1 - col. 2)	(see instru.)	Insurance	Taxes	Related Costs	cols. 5-7)						
*		1	2	3	4	5	6	7	8						
1 	Old Capital Related Costs-Buildings and Fixtures	X	X	X		X	X	X		1 					
2 	Old Capital Related Costs-Movable Equipment	X	X	X		X	X	X		2 					
3 	New Capital Related Costs-Buildings and Fixtures	X	X	X		X	X	X		3 					
4 	New Capital Related Costs-Movable Equipment	X	X	X		X	X	X		4 					
5 	Total (sum of lines 1-4)	X	X	X	1.000000	X	X	X		5 					
															
					   SUMMARY OF OLD AND NEW CAPITAL										
								Other Capital-	Total (1)						
						Insurance	Taxes	Related Costs	(sum of 						
	Description		Depreciation	Lease	Interest	(see instru.)	(see instru.)	(see instru.)	cols. 9-14)						
*			9	10	11	12	13	14	15						
1 	Old Capital Related Costs-Buildings and Fixtures		X	X	X				X	1 					
2 	Old Capital Related Costs-Movable Equipment		X	X	X				X	2 					
3 	New Capital Related Costs-Buildings and Fixtures		X	X	X				X	3 					
4 	New Capital Related Costs-Movable Equipment		X	X	X				X	4 					
5 	Total (sum of lines 1-4)		X	X	X				X	5 					
" (1)  The amounts on lines 1 thru 4 must equal the corresponding amounts on Worksheet A, column 7, lines 1 thru 4.  Columns 9 through 14 should include related"															
	"Worksheet A-6 reclassificatons, Worksheet A-8 adjustments, and Worksheet A-8-1  related organizations and home office costs. (See instructions.)"														
															
															
"PART IV - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 THRU 4 "															
					   SUMMARY OF OLD AND NEW CAPITAL										
								Other Capital-	Total (1)						
						Insurance	Taxes	Related Costs	(sum of 						
	Description		Depreciation	Lease	Interest	(see instru.)	(see instru.)	(see instru.)	cols. 9-14)						
*			9	10	11	12	13	14	15						
1 	Old Capital Related Costs-Buildings and Fixtures		X	X	X				X	1 					
2 	Old Capital Related Costs-Movable Equipment		X	X	X				X	2 					
3 	New Capital Related Costs-Buildings and Fixtures		X	X	X				X	3 					
4 	New Capital Related Costs-Movable Equipment		X	X	X				X	4 					
5 	Total (sum of lines 1-4)		X	X	X				X	5 					
(1)	"The  amount in columns 9 thru 14 must equal the amount on Worksheet A, column 2, lines 1 thru 4.  Enter in each column the approporiate amounts including any directly assigned cost "														
	"which may have been included in Worksheet A, column 2, lines 1 thru 4."														
*	All lines numbers except line 5 are to be consistent with Worksheet A line numbers for capital cost centers.														
															
															
"FORM CMS-2552-96 (12/1999)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3612 , 3612.2 AND 3612.3)"															
															
															
Rev. 6										          36-517