Mendota Lutheran Home-2001-0011593 - HFS - State of Illinois

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Mendota Lutheran Home XX General Information Question 12 2001 33 Other(specify) Chaplin 633 633 11,055 17.46 33 34 TOTAL (lines 1 - 33) 261,202 283,318 $ 3,005,683 * $ 10.61 34 * This total must agree with page 4, column 1, line 45. ** See instructions. 31 of 31
Mendota Lutheran Home XX General Information Question 12 2001 STATE OF ILLINOIS Page 21 Facility Name & ID Number XIX. SUPPORT SCHEDULES Mendota Lutheran Home # 0011593 Report Period Beginning: 01/01/01 Ending: 12/31/01 A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions Name Function % Amount Description Amount Description Amount Chris S. Csernus Administration 0 $ 70,357 Workers' Compensation Insurance $ 83,424 IDPH License Fee $ 100 Unemployment Compensation Insurance Advertising: Employee Recruitment 10,439 FICA Taxes 218,270 Health Care Worker Background Check 1,501 Employee Health Insurance 151,280 (Indicate # of checks performed 135 ) Employee Meals Membership dues 5,753 Illinois Municipal Retirement Fund (IMRF)* Subscriptions & publications 1,984 Employer share 401K pension 28,012 Advertising, promotion & other 19,952 TOTAL (agree to Schedule V, line 17, col. 1) Employee awards & meetings 9,296 License for corporation 15 (List each licensed administrator separately.) $ 70,357 Employee physicals 1,441 Bank fees & charges 1,064 B. Administrative - Other Civic club dues (373) Less: Public Relations Expense (5,006) Description Amount Non-allowable advertising (3,376) Administration consultant - account reviews Computer consulting $ 1,537 Yellow page advertising (458) TOTAL (agree to Schedule V, $ 491,723 TOTAL (agree to Sch. V, $ 31,595 line 22, col.8) line 20, col. 8) TOTAL (agree to Schedule V, line 17, col. 3) $ 1,537 E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar** (Attach a copy of any management service agreement) to Owners or Employees C. Professional Services Description Amount Vendor/Payee Type Amount Description Line # Amount Duane, Morris & Heckscher attorney $ 7,066 $ Out-of-State Travel $ Hinshaw & Culbertson labor attorney 1,662 reimburse auto mileage - employees Amcore Bank account analysis 277 for local travel required by home 345 Bokus & May, P.C. reporting & support 4,632 In-State Travel 3,523 First State Bank audit seminar, bond admin 584 Lindgren, Callihan, Vanosdol audit 8,250 Terry's Computer Shack computer consultant 8,091 Quick Care clinical support 1,959 Seminar Expense 7,634 30 of 31 Entertainment Expense ( )
Page 1 and 2: FOR OHF USE Mendota Lutheran Home X
Page 3 and 4: Mendota Lutheran Home XX General In
Page 19 and 20: * Total must agree with the amount
Page 23 and 24: 25 TOTALS Mendota Lutheran Home XX
Page 41 and 42: your facility. Drop-out costs can o
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Page 61: Nelson, Tammie 239 $1,482.61 Dietar

Mendota Lutheran Home-2001-0011593 - HFS - State of Illinois

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