"Pension Prefunding Worksheet
(Determination of a Pension Prefunding Balance and Installment is Optional)"														
														
Provider Name:									#					
	Step 1: Determine the Eligible Lookback Period													
														
(1)	Wage Index FY ending									2013				
(2)	Beginning of Provider Cost Reporting Period Used for Wage Index Year shown on Line 1													
(3)	Prefunding Lookback Period Ends (One day prior to date shown on Line 2)													
(4)	"Earliest Beginning Date for Lookback Period (Start of First Provider Cost Reporting Period Commencing on or After October 1, 2002)"													
														
	Step 2: Pension Contribution & Reported Pension Costs During the Lookback Period													
														
(5)	Complete the Table Below for each Provider Cost Reporting Period in the Eligible Lookback Period													
														
		Column A				Column B		Column C		Column D		Error Checking		
		"Cost Reporting Period
(If X appears, period is not in the lookback range and must be excluded)"								Enter X to		Not	Missing/overlapping	Date ranges not
	Row	Beginning		Ending		Contributions		Pension Costs for Wage Index		Exclude Period		Consecutive	Date Range	Chronological
	1													
	2													
	3													
	4													
	5													
	6													
	7													
	8													
	9													
	10													
	11													
	12													
	13													
	14													
	15													
	16													
	17													
	18													
(6)	Total Columns B & C for periods not marked excluded in Column D.					$0		$0						
(7)	"Prefunding Balance (Line 6 Column 2 B minus Line 6 Column C, but not less than ""0"")"									$0				
(8)	Annual Prefunding Installment (Line 7 divided by 10)							Transfer to Line 17 of Wage Index Pension Cost  Worksheet>   		$0				
														
														
Prepared by		     							Date					
