Wage Index Pension Cost Worksheet										
Provider Name:								#		
	Step 1: Determine the 3-Year Averaging Period									
										
(1)	Wage Index FY ending								2019	
(2)	Provider cost reporting period used for Wage Index year shown on Line 1							to		
(3)	End of the 3-year averaging period (Final date from cost reporting period shown on Line 2.)									
(4)	Beginning of the 3-year averaging period (Subtract 36 months from End date 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)								
(5)	Effective date of pension plan									
(6)	First day of the provider cost reporting period containing the pension plan effective date									
										
	Step 3: Average Pension Contributions During the Averaging Period									
										
(7)	Beginning date of averaging period from Line 4 or Line 6									
(8)	Ending date of averaging period from Line 3									
(9)	Enter provider contributions made during the averaging period shown on Lines 7 & 8									
	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				
										
(10)	Total Number of Months Included in Averaging Period								36	
(11)	Total Contributions Made During Averaging Period								$0	
(12)	Average Monthly Contribution (Line 11 divided by line 10)								$0	
(13)	Number of Months in Provider Cost Reporting Period shown on Line 2								0	
(14)	Average Pension Contributions (Line 12 multiplied by Line 13)								$0	
										
	Step 4: Total Pension Cost for Wage Index									
	"If Wage Index FY shown on Line 1 is after 2022, enter ""0"" on Lines 16 and 17."									
(15)	"Annual Prefunding Installment from Line 8 of Pension Prefunding Worksheet, if applicable (see instructions)"									
(16)	Reportable Prefunding Installment (Line 15 multiplied by Line 13/12)								$0	
(17)	Total Pension Cost for Wage Index (Line 14 + Line 16)								$0	
										
										
Prepared by								Date 		
