Wage Index Pension Cost Worksheet										
Provider Name:								#		
	Step 1: Determine the 3-Year Averaging Period									
										
(1)	Wage Index FY ending								2013	
(2)	Provider cost reporting period used for Wage Index year shown on Line 1							to		
(3)	Midpoint of provider's cost reporting period shown on Line 2 (+ or - in highlighted cell to adjust to first of month)							+		
(4)	Beginning the 3-year averaging period (Subtract 18 months from midpoint shown on Line 3)									
(5)	End of the 3-year averaging period (Add 18 months to midpoint shown on Line 3.)									
										
	Step 2: Adjust Averaging Period for a New Plan (See instructions)									
		(Leave this section blank if Provider has not elected to use an adjusted averaging period)								
(6)	Effective date of pension plan									
(7)	First day of the provider cost reporting period containing the pension plan effective date									
(8)	"Start adjusted averaging period (Date on Line 7 if first of the month, or +/ - in highlighted cell to adjust to first of month)"							+		
	"If this date occurs after the period shown on Line 2 (Step 1), stop here and see instructions.  No cost is reportable for a period which is excluded from the averaging period."									
										
	Step 3: Average Pension Contributions During the Averaging Period									
										
(9)	Beginning date of averaging period from Line 4 or Line 8									
(10)	Ending date of averaging period from Line 5									
(11)	Enter provider contributions made during the averaging period shown on Lines 9 & 10									
	Data may be grouped within the averaging period to agree with documentation records (enter beginning date of grouped date range) 									
			Deposit Date(s)		Contributions 		Deposit Date(s)		Contributions 	
		1				19				
		2				20				
		3				21				
		4				22				
		5				23				
		6				24				
		7				25				
		8				26				
		9				27				
		10				28				
		11				29				
		12				30				
		13				31				
		14				32				
		15				33				
		16				34				
		17				35				
		18				36				
										
(12)	Total Number of Months Included in Averaging Period								36	
(13)	Total Contributions Made During Averaging Period								$0	
(14)	Average Monthly Contribution (Line 13 divided by line 12)								$0	
(15)	Number of Months in Provider Cost Reporting Period shown on Line 2								0	
(16)	Average Pension Contributions (Line 14 multiplied by Line 15)								$0	
										
	Step 4: Total Pension Cost for Wage Index									
	"If Wage Index FY shown on Line 1 is after 2022, enter ""0"" on Lines 17 and 18."									
(17)	"Annual Prefunding Installment from Line 8 of Pension Prefunding Worksheet, if applicable"									
(18)	Reportable Prefunding Installment (Line 17 multiplied by Line 15/12)								$0	
(19)	Total Pension Cost for Wage Index (Line 16 + Line 18)								$0	
										
										
Prepared by								Date 		
