Income Statement

PC 741 - Affinity Medical Center

Actual Budget Variance

Revenue
Contract Sales $0.00 $65,265.52 -$65,265.52
Monthly Contract Caps $0.00 $0.00 $0.00
Supplemental:
Labor $9,101.92 $0.00 $9,101.92
Patient Day Adjustment $0.00 $0.00 $9,101.92
Food Revenue $15,093.92 $15,000.00 $93.92
Total Revenue $24,195.84 $80,265.52 -$56,069.68

Compensation Expense
Management Labor $0.00 $23,162.92 -$23,162.92
Productive Labor $0.00 $33,762.96 -$33,762.96
Non-Productive Labor $0.00 $892.60 -$892.60
Contract Services $0.00 $0.00 $0.00
Total Labor Expense $0.00 $57,818.48 -$57,818.48

Operating Expense
Supplies $458.80 $500.00 -$41.20
Food & Beverage $0.00 $0.00 $0.00
Linen $0.00 $0.00 $0.00
Uniforms $0.00 $0.00 $0.00
Total Operating Expense $458.80 $500.00 -$41.20

Total Profit or Loss $23,737.04 $21,947.04 $1,790.00

Supplemental Labor
PC 741 - Affinity Medical Center
Instructions:
1) Verify Supplemental Labor Bill Rate and input into Cell C8, if applicable
2) Enter date and event description.
3) Input hours worked OR provide the flat fee you would like charged to the client. D

Supplemental Labor Bill Rate: $13.96

Date Event Description HoursCalculated Amount

1-7 Oct FTE Increase 166 $ 2,317.36
8-14 Oct FTE Increase 148.25 $ 2,069.57
15-21 Oct FTE Increase 121.25 $ 1,692.65
22-28 Oct FTE Increase 131.25 $ 1,832.25
29-31 Oct FTE Increase 85.25 $ 1,190.09
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
applicable

e charged to the client. Do NOT input both pieces of information

OR Flat Fee Amount

$0.00 $ 2,317.36
$ 2,069.57
$ 1,692.65
$ 1,832.25
$ 1,190.09
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$9,101.92 Total Invoice Amount
Patient Days
PC 741 - Affinity Medical Center

Instructions:
1) Please use the "Patient Day Tracking" table to record Patient Days on dail
2) Verify and update the Number of Days in the Month in cell C10 if necessary

Annual
Number of Days in Patient Day Monthly
Actual Patient Days Month Baseline Patient Day Baseline

2,176.00 31 25,509.00 2,166.52

A B

Patient Day Tracking Tickmarks and notes:

Date A
10/1/2017 73
B
10/2/2017 81
10/3/2017 80 C
10/4/2017 70 D
10/5/2017 73
10/6/2017 64
10/7/2017 59
10/8/2017 55
10/9/2017 70
10/10/2017 67
10/11/2017 70
10/12/2017 73
10/13/2017 59
10/14/2017 64
10/15/2017 58
10/16/2017 61
10/17/2017 66
10/18/2017 76
10/19/2017 77
10/20/2017 85
10/21/2017 78
10/22/2017 76
10/23/2017 74
10/24/2017 74
10/25/2017 71
10/26/2017 72
10/27/2017 74
10/28/2017 60
10/29/2017 69
10/30/2017 72
10/31/2017 75
TOTAL 2,176.00
to record Patient Days on daily basis. End of month total will auto populate to Cell B10.
Month in cell C10 if necessary.

Daily Rate Variance Bill Back

9.48 $0.00
C D

Annual Patient Day Baseline as outlined in Contract.

Calculated as Annual Patient Day Baseline divided by 365 and multiplied by
number of days in the month (Cell C10).
Daily Rate as outlined in the Contract.
Assuming that the contract allows for HHS to bill back for Patient Day Variance.
Retail Sales
PC 741 - Affinity Medical Center

Cash

Over / Total Employee Charge Credit

Date Cash Short Cash Collected (Payroll Deduct) Card
10/01/17 $67.27 $0.00 $67.27 $76.46 $8.97
10/02/17 $354.86 $0.45 $355.31 $868.70 $169.45
10/03/17 $419.54 -$0.46 $419.08 $881.86 $128.09
10/04/17 $384.16 $6.08 $390.24 $1,075.59 $213.90
10/05/17 $446.13 -$4.90 $441.23 $911.78 $218.90
10/06/17 $391.62 $1.09 $392.71 $683.34 $207.66
10/07/17 $79.95 $0.25 $80.20 $92.60 $22.62
10/08/17 $83.49 $0.08 $83.57 $45.90 $35.85
10/09/17 $406.71 -$0.39 $406.32 $785.72 $121.68
10/10/17 $334.36 $0.00 $334.36 $840.60 $179.87
10/11/17 $419.51 $1.60 $421.11 $852.39 $157.96
10/12/17 $364.79 $0.54 $365.33 $886.57 $176.65
10/13/17 $297.98 $3.68 $301.66 $884.02 $172.62
10/14/17 $62.18 $0.00 $62.18 $111.61 $21.19
10/15/17 $44.17 $0.00 $44.17 $85.96 $11.67
10/16/17 $329.79 $0.50 $330.29 $695.00 $110.66
10/17/17 $330.11 $4.83 $334.94 $1,047.45 $178.78
10/18/17 $334.55 $0.10 $334.65 $910.18 $122.07
10/19/17 $332.81 $2.98 $335.79 $863.58 $165.54
10/20/17 $381.75 $0.00 $381.75 $849.39 $148.44
10/21/17 $47.69 $0.00 $47.69 $106.60 $19.62
10/22/17 $38.74 $0.00 $38.74 $78.36 $13.01
10/23/17 $320.68 -$0.80 $319.88 $978.80 $107.73
10/24/17 $352.77 $0.31 $353.08 $922.67 $181.84
10/25/17 $341.67 $0.00 $341.67 $857.94 $216.35
10/26/17 $316.95 $0.00 $316.95 $930.68 $181.89
10/27/17 $330.76 -$5.00 $325.76 $722.89 $162.43
10/28/17 $64.35 -$2.00 $62.35 $91.45 $25.10
10/29/17 $39.18 $0.00 $39.18 $64.07 $11.38
10/30/17 $320.89 -$0.75 $320.14 $855.18 $204.88
10/31/17 $330.63 -$1.54 $329.09 $892.40 $133.46

Totals $8,370.04 $6.65 $8,376.69 $19,949.74 $3,830.26

 Retail Sales
Free Meals
Total Cash + PR
Deduct + Credit
Card Meal Ticket Doctor Intern/Res Anesthesia Volunteer
$152.70 $0.00 $0.00 $24.96 $0.00 $3.42
$1,393.46 $1.60 $0.00 $133.71 $0.00 $149.99
$1,429.03 $5.00 $2.50 $162.47 $0.00 $70.70
$1,679.73 $14.61 $0.00 $119.32 $0.00 $165.97
$1,571.91 $0.00 $0.00 $135.06 $0.00 $70.95
$1,283.71 $0.00 $2.00 $97.87 $0.00 $118.53
$195.42 $0.00 $0.00 $14.05 $0.00 $6.38
$165.32 $0.00 $0.00 $14.05 $0.00 $1.30
$1,313.72 $5.00 $0.00 $79.89 $0.00 $101.47
$1,354.83 $13.96 $0.00 $116.10 $7.25 $94.07
$1,431.46 $14.42 $0.00 $70.58 $0.00 $128.28
$1,428.55 $18.09 $0.00 $109.38 $0.00 $90.81
$1,358.30 $8.49 $0.00 $80.44 $0.00 $151.03
$194.98 $0.00 $0.00 $11.70 $0.00 $0.00
$141.80 $0.00 $0.00 $13.24 $0.00 $0.00
$1,135.95 $80.21 $0.00 $89.78 $0.00 $95.76
$1,561.17 $14.30 $0.00 $143.00 $0.00 $143.58
$1,366.90 $0.00 $0.00 $105.28 $0.00 $114.55
$1,364.91 $17.61 $0.00 $104.64 $0.00 $55.31
$1,379.58 $4.81 $2.75 $137.70 $0.00 $106.82
$173.91 $0.00 $0.00 $11.81 $0.00 $0.00
$130.11 $0.00 $0.00 $43.25 $0.00 $3.50
$1,406.41 $7.87 $0.00 $92.92 $0.00 $131.37
$1,457.59 $11.21 $0.00 $128.24 $0.00 $131.56
$1,415.96 $9.15 $0.00 $92.08 $0.00 $141.14
$1,429.52 $10.41 $0.00 $85.12 $0.00 $114.82
$1,211.08 $8.68 $0.00 $72.20 $0.00 $133.16
$178.90 $0.00 $0.00 $14.00 $0.00 $5.10
$114.63 $0.00 $0.00 $0.00 $0.00 $1.60
$1,380.20 $9.43 $0.00 $79.98 $0.00 $140.83
$1,354.95 $5.00 $1.80 $81.40 $0.00 $118.54

$32,156.69 $259.85 $9.05 $2,464.22 $7.25 $2,590.54

 Safe

Dollar Bills
Deposited
Dietary Total Revenue Net Sales into New Safe
$0.00 $181.08 $181.08 $67.00
$3.90 $1,682.21 $1,682.21 $354.00
$0.75 $1,670.91 $1,670.91 $418.00
$0.00 $1,973.55 $1,973.55 $389.00
$0.00 $1,782.82 $1,782.82 $440.00
$0.00 $1,501.02 $1,501.02 $392.00
$0.00 $215.60 $215.60 $80.00
$0.00 $180.59 $180.59 $83.00
$0.00 $1,500.47 $1,500.47 $406.00
$0.00 $1,586.21 $1,586.21 $333.00
$4.60 $1,647.74 $1,647.74 $420.00
$1.40 $1,647.69 $1,647.69 $364.00
$5.59 $1,600.17 $1,600.17 $299.00
$0.00 $206.68 $206.68 $62.00
$0.00 $155.04 $155.04 $44.00
$9.35 $1,410.55 $1,410.55 $329.00
$1.69 $1,858.91 $1,858.91 $334.00
$0.00 $1,586.63 $1,586.63 $334.00
$10.51 $1,550.00 $1,550.00 $335.00
$4.59 $1,636.25 $1,636.25 $381.00
$0.00 $185.72 $185.72 $47.00
$0.00 $176.86 $176.86 $38.00
$11.45 $1,650.82 $1,650.82 $319.00
$0.75 $1,729.04 $1,729.04 $352.00
$10.52 $1,668.85 $1,668.85 $339.00
$0.00 $1,639.87 $1,639.87 $316.00
$13.32 $1,443.44 $1,443.44 $324.00
$0.00 $200.00 $200.00 $62.00
$0.00 $116.23 $116.23 $39.00
$0.00 $1,611.19 $1,611.19 $319.00
$5.83 $1,569.06 $1,569.06 $329.00

$84.25 $37,565.20 $0.00 $37,565.20 $8,348.00

Transfer to Depository XX7609

Transfer from PC 741 XX4143

 Safe

Coins
Coins/Checks converted to
Safe Will Not Dollar Bills
Accept Deposited
$0.27 $1.00
$1.31 $1.00
$1.08 $1.00
$1.24 $1.00
$1.23 $1.00
$0.71 $1.00
$0.20 $1.00
$0.57 $1.00
$0.32 $1.00
$1.36 $1.00
$1.11 $1.00
$1.33 $1.00
$2.66 $1.00
$0.18 $1.00
$0.17 $1.00
$1.29 $1.00
$0.94 $1.00
$0.65 $1.00
$0.79 $1.00
$0.75 $1.00
$0.69 $1.00
$0.74 $1.00
$0.88 $1.00
$1.08 $1.00
$2.67 $1.00
$0.95 $1.00
$1.76 $1.00
$0.35 $1.00
$0.18 $1.00
$1.14 $1.00
$0.09 $1.00

$28.69 $0.00 $1.00

ansfer to Depository XX7609

ansfer from PC 741 XX4143

Monthly Contract Caps
PC 741 - Affinity Medical Center
Note: As stated in the contract, included in the monthly fee are budgeted food allotments in a
allotments, Hospital will be calculated and billed separately for these overages, at actua

FOR TRACKING PURPOSES ONLY. These i

Category Week 1 Week 2 Week 3
Catering $180.50 $183.00 $380.00
Floorstocks $1,302.37 $1,423.54 $1,441.24
Nourishments
Supplements $86.42 $72.70 $73.36
Guest Meals
ER Meals
Outpatient Meals
Observation Meals
Free Meals (Volunteers, Admin, Etc)
Doctor's Charge Meals
Doctor's Lounge

$1,569.29 $1,679.24 $1,894.60

Tickmarks and notes:

A Client will be invoiced when the total of the actual expenses is greater than the
 are budgeted food allotments in applicable food categories. In the event that the Hospital exceeds these
arately for these overages, at actual cost. HHS management is responsible for inventory and monthly reporting.

SES ONLY. These items will not be Billed Back.

Week 4 Week 5 Actual Budget Bill Back
$1,037.00 $1,780.50
$1,559.32 $644.81 $6,371.28
$0.00
$86.31 $318.79
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

$2,682.63 $644.81 $8,470.57 $0.00 $8,470.57

al expenses is greater than the total of the aggregate bu

Total Invoice A
Amount
Payroll
PC 741 - Affinity Medical
Center

Week End Week End Week End

Description 10/07 10/14 10/21
Reg Hrs
OT Hrs
PTO Hrs
Total Hours 0.00 0.00 0.00

Week End Week End Week End

Hourly 10/07 10/14 10/21
Regular ($'s)
Overtime ($'s)
PTO ($'s)
Total Hourly $ - $ - $ -

Week End Week End Week End

Salary 10/07 10/14 10/21
Management
Total Salary $ - $ - $ -

Total Labor Expense $ - $ - $ -

 Week End Days End
10/28 10/31 Total
0.00
0.00
0.00
0.00 0.00 0.00

Week End Days End

10/28 10/31 Total
$ -
$ -
$ -
$ - $ - $ -

Week End Days End

10/28 10/31 Total
$ -
$ - $ - $ -

$ - $ - $ -
Expense Tracking
PC 741 - Affinity Medical Center
Instructions:
1) Enter all Invoices that require payment and are the responsibility of HHS. (Bill back should be done o
2) Using the drop down list, select the most appropriate expense classification (Contract Services, Supp
a) AP will be reviewing expense selections for appropriateness and will make changes if nece
3) Invoices that contain expenses that pertain to multiple expense categories should be listed on separa
a) Use your best judgment to determine the amount of the invoice that pertains to each expen
b) AP will be reviewing expense amounts for appropriateness and will make changes if necess

FOR USE BY FIELDInvoice Amount or

Appropriate
Vendor Name Invoice Number Invoice Date Portion Expense Category
Food Service Resources PSI347282 10/19/2017 $170.00 Supplies
Food Service Resources PSI347942 10/30 $118.80 Supplies
Food Service Resources PSI346332 10/4/2017 $170.00 Supplies
S. (Bill back should be done on an exception basis.)
tion (Contract Services, Supplies, Food & Beverage, etc.).
will make changes if necessary.
es should be listed on separate lines.
hat pertains to each expense category.
will make changes if necessary.

Food &
Contract Services Supplies Beverage Linen Uniforms
$0.00 $170.00 $0.00 $0.00 $0.00
$0.00 $118.80 $0.00 $0.00 $0.00
$0.00 $170.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 $0.00
$0.00 $458.80 $0.00 $0.00 $0.00
 FOR USE BY AP

Bill Back Received Comments

$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Invoices Paid by Hospital
PC 741 - Affinity Medical Center
Instructions:
1) Verify and update Budget in Cell M2, if necessary.
2) Enter all invoices that will be paid by the Hospital

FOR TRACKING PURPOSES ONLY. Th

Invoice Amount or
Vendor Name Invoice Number Invoice Date Appropriate Portion
Cadillac Coffee Company 514-452140 10/2/2017 $ 468.98
Reiter Dairy / Akron 945452 10/2/2017 $ 124.24
Klosterman Baking Company 171002329015 10/2/2017 $ 61.30
Premier ProduceOne 1287230 10/3/2017 $ 598.77
Klosterman Baking Company 171003329025 10/3/2017 $ 108.54
Gordon Food Service 180957252 10/3/2017 $ 298.24
Gordon Food Service 180957252 10/3/2017 $ 4,559.55
Food Service Resources PSI346332 10/4/2017 $ 437.76
Gordon Food Service 763153222 10/5/2017 $ 128.96
Edward Don & Company 21380284 10/5/2017 $ 168.95
Premier ProduceOne 1289756 10/5/2017 $ 528.42
Reiter Dairy / Akron 946033 10/5/2017 $ 170.79
Klosterman Baking Company 171005329021 10/5/2017 $ 22.30
Coca Cola Bottling Co 9007200801 10/5/2017 $ 3,465.26
Gordon Food Service 181042333 10/6/2017 $ 520.50
Gordon Food Service 181042333 10/6/2017 $ 4,164.32
Klosterman Baking Company 171006329017 10/6/2017 $ 46.91
Giant Eagle 180432912446 10/7/2017 $ 10.67
Gordon Food Service 763153384 10/8/2017 $ 174.12
Blue Turtle Services 436-004924 10/6/2017 $ 175.00
Gordon Food Service 763153402 10/9/2017 $ 64.70
Klosterman Baking Company 171009329019 10/9/2017 $ 57.89
Premier ProduceOne 95106 10/9/2017 $ (19.62)
Edward Don & Company 21394508 10/9/2017 $ 500.55
Cadillac Coffee Company 514-452204 10/10/2017 $ 370.36
Klosterman Baking Company 17283329020 10/10/2017 $ 83.70
Gordon Food Service 763153441 10/10/2017 $ 39.57
Premier ProduceOne 1293034 10/10/2017 $ 519.01
Gordon Food Service 181117724 10/10/2017 $ 315.10
Gordon Food Service 181117724 10/10/2017 $ 4,752.34
Reiter Dairy / Akron 946556 10/10/2017 $ 134.56
Cozzini Bros C4290158 10/11/2017 $ 74.00
Klosterman Baking Company 17285329024 10/12/2017 $ 93.17
Coca Cola Bottling Co 8990201888 10/12/2017 $ 2,492.49
Premier ProduceOne 1296164 10/13/2017 $ 474.66
Gordon Food Service 181202709 10/13/2017 $ 845.71
Gordon Food Service 181202709 10/13/2017 $ 4,014.19
Reiter Dairy / Akron 947100 10/13/2017 $ 155.65
Digi Smart Temps INVST009137 10/1/2017 $ 967.80
Blue Turtle Services 436-004998 10/16/2017 $ 175.00
Klosterman Baking Company 171016329017 10/16/2017 $ 68.73
Gordon Food Service 181277741 10/17/2017 $ 489.70
Gordon Food Service 181277741 10/17/2017 $ 3,586.04
Premier ProduceOne 1299788 10/17/2017 $ 586.89
Giant Eagle 180439636406 10/17/2017 $ 5.99
Klosterman Baking Company 171017329018 10/17/2017 $ 111.54
Reiter Dairy / Akron 947572 10/17/2017 $ 138.76
Gordon Food Service 763153799 10/18/2017 $ 240.63
Giant Eagle 180440299417 10/18/2017 $ 25.73
Michael's Finer Meats & Seafoods 1848374 10/19/2017 $ 307.54
EcoLab 7203881 10/9/2017 $ 440.47
Klosterman Baking Company 171019329019 10/19/2017 $ 16.11
Gordon Food Service 181363547 10/20/2017 $ 537.18
Gordon Food Service 181363547 10/20/2017 $ 4,315.12
Premier ProduceOne 1300524 10/20/2017 $ 700.50
Reiter Dairy / Akron 947991 10/20/2017 $ 111.93
Klosterman Baking Company 171020329014 10/20/2017 $ 60.86
Gordon Food Service 763154000 10/22/2017 $ 97.26
Klosterman Baking Company 171023329022 10/23/2017 $ 44.94
Gordon Food Service 763154023 10/23/2017 $ 145.32
Cadillac Coffee Company 514-452309 10/23/2017 $ 536.86
Blue Turtle Services 436-005070 10/20/2017 $ 175.00
Food Service Resources PSI347282 10/19/2007 $ 435.76
Gordon Food Service 181440575 10/24/2017 $ 929.68
Gordon Food Service 181440575 10/24/2017 $ 4,006.81
Premier ProduceOne 1305452 10/24/2017 $ 406.03
Food Service Resources PSI347573 10/24/2017 $ 425.20
Reiter Dairy / Akron 948411 10/24/2017 $ 121.52
Klosterman Baking Company 171024329024 10/24/2017 $ 83.19
Edward Don & Company 21460808 10/24/2017 $ 252.35
Cozzini Bros C4341529 10/25/2017 $ 74.00
Gordon Food Service 763154130 10/25/2017 $ 15.92
Gordon Food Service 763154172 10/26/2017 $ 21.97
Klosterman Baking Company 171026329022 10/26/2017 $ 63.64
Premier ProduceOne 98314 10/27/2017 $ (8.55)
Premier ProduceOne 1308130 10/27/2017 $ 240.53
Edwards Business Equipment 160474 10/26/2017 $ 192.15
Gordon Food Service 763154243 10/27/2017 $ 88.78
Reiter Dairy / Akron 948985 10/27/2017 $ 163.75
Klosterman Baking Company 171027329016 10/27/2017 $ 63.92
Gordon Food Service 181525635 10/27/2017 $ 461.49
Gordon Food Service 181525635 10/27/2017 $ 2,991.06
Gordon Food Service 10503634 10/27/2017 $ (38.68)
Gordon Food Service 10503646 10/27/2017 $ (38.39)
Giant Eagle 180447981871 10/29/2017 $ 5.98
Blue Turtle Services 436-005139 10/30/2017 $ 200.50
Klosterman Baking Company 171030329016 10/30/2017 $ 54.42
Coca Cola Bottling Co 8988201920 10/30/2017 $ (124.30)
Cadillac Coffee Company 514-452373 10/30/2017 $ 595.64
Coca Cola Bottling Co 8988201921 10/30/2017 $ 968.88
Gordon Food Service 181600856 10/31/2017 $ 400.04
Gordon Food Service 181600856 10/31/2017 $ 3,251.62
Premier ProduceOne 1311087 10/31/2017 $ 543.24
Klosterman Baking Company 171031329020 10/31/2017 $ 75.66
Reiter Dairy / Akron 949497 10/31/2017 $ 137.28
Premier ProduceOne 1311920 10/31/2017 $ 9.70
Food Service Resources PSI347942 10/30/2017 $ 243.10
 ssary.
ospital

RPOSES ONLY. These items will not be Billed Back.

Food &
Expense Category Contract Services Supplies Beverage Linen
Food & Beverage $0.00 $0.00 $468.98 $0.00
Food & Beverage $0.00 $0.00 $124.24 $0.00
Food & Beverage $0.00 $0.00 $61.30 $0.00
Food & Beverage $0.00 $0.00 $598.77 $0.00
Food & Beverage $0.00 $0.00 $108.54 $0.00
Supplies $0.00 $298.24 $0.00 $0.00
Food & Beverage $0.00 $0.00 $4,559.55 $0.00
Supplies $0.00 $437.76 $0.00 $0.00
Food & Beverage $0.00 $0.00 $128.96 $0.00
Supplies $0.00 $168.95 $0.00 $0.00
Food & Beverage $0.00 $0.00 $528.42 $0.00
Food & Beverage $0.00 $0.00 $170.79 $0.00
Food & Beverage $0.00 $0.00 $22.30 $0.00
Food & Beverage $0.00 $0.00 $3,465.26 $0.00
Supplies $0.00 $520.50 $0.00 $0.00
Food & Beverage $0.00 $0.00 $4,164.32 $0.00
Food & Beverage $0.00 $0.00 $46.91 $0.00
Food & Beverage $0.00 $0.00 $10.67 $0.00
Food & Beverage $0.00 $0.00 $174.12 $0.00
Contract Services $175.00 $0.00 $0.00 $0.00
Food & Beverage $0.00 $0.00 $64.70 $0.00
Food & Beverage $0.00 $0.00 $57.89 $0.00
Food & Beverage $0.00 $0.00 -$19.62 $0.00
Supplies $0.00 $500.55 $0.00 $0.00
Food & Beverage $0.00 $0.00 $370.36 $0.00
Food & Beverage $0.00 $0.00 $83.70 $0.00
Food & Beverage $0.00 $0.00 $39.57 $0.00
Food & Beverage $0.00 $0.00 $519.01 $0.00
Supplies $0.00 $315.10 $0.00 $0.00
Food & Beverage $0.00 $0.00 $4,752.34 $0.00
Food & Beverage $0.00 $0.00 $134.56 $0.00
Contract Services $74.00 $0.00 $0.00 $0.00
Food & Beverage $0.00 $0.00 $93.17 $0.00
Food & Beverage $0.00 $0.00 $2,492.49 $0.00
Food & Beverage $0.00 $0.00 $474.66 $0.00
Supplies $0.00 $845.71 $0.00 $0.00
Food & Beverage $0.00 $0.00 $4,014.19 $0.00
Food & Beverage $0.00 $0.00 $155.65 $0.00
Contract Services $967.80 $0.00 $0.00 $0.00
Contract Services $175.00 $0.00 $0.00 $0.00
Food & Beverage $0.00 $0.00 $68.73 $0.00
Supplies $0.00 $489.70 $0.00 $0.00
Food & Beverage $0.00 $0.00 $3,586.04 $0.00
Food & Beverage $0.00 $0.00 $586.89 $0.00
Food & Beverage $0.00 $0.00 $5.99 $0.00
Food & Beverage $0.00 $0.00 $111.54 $0.00
Food & Beverage $0.00 $0.00 $138.76 $0.00
Food & Beverage $0.00 $0.00 $240.63 $0.00
Food & Beverage $0.00 $0.00 $25.73 $0.00
Food & Beverage $0.00 $0.00 $307.54 $0.00
Supplies $0.00 $440.47 $0.00 $0.00
Food & Beverage $0.00 $0.00 $16.11 $0.00
Supplies $0.00 $537.18 $0.00 $0.00
Food & Beverage $0.00 $0.00 $4,315.12 $0.00
Food & Beverage $0.00 $0.00 $700.50 $0.00
Food & Beverage $0.00 $0.00 $111.93 $0.00
Food & Beverage $0.00 $0.00 $60.86 $0.00
Food & Beverage $0.00 $0.00 $97.26 $0.00
Food & Beverage $0.00 $0.00 $44.94 $0.00
Food & Beverage $0.00 $0.00 $145.32 $0.00
Food & Beverage $0.00 $0.00 $536.86 $0.00
Contract Services $175.00 $0.00 $0.00 $0.00
Supplies $0.00 $435.76 $0.00 $0.00
Supplies $0.00 $929.68 $0.00 $0.00
Food & Beverage $0.00 $0.00 $4,006.81 $0.00
Food & Beverage $0.00 $0.00 $406.03 $0.00
Supplies $0.00 $425.20 $0.00 $0.00
Food & Beverage $0.00 $0.00 $121.52 $0.00
Food & Beverage $0.00 $0.00 $83.19 $0.00
Food & Beverage $0.00 $0.00 $252.35 $0.00
Contract Services $74.00 $0.00 $0.00 $0.00
Food & Beverage $0.00 $0.00 $15.92 $0.00
Food & Beverage $0.00 $0.00 $21.97 $0.00
Food & Beverage $0.00 $0.00 $63.64 $0.00
Food & Beverage $0.00 $0.00 -$8.55 $0.00
Food & Beverage $0.00 $0.00 $240.53 $0.00
Supplies $0.00 $192.15 $0.00 $0.00
Food & Beverage $0.00 $0.00 $88.78 $0.00
Food & Beverage $0.00 $0.00 $163.75 $0.00
Food & Beverage $0.00 $0.00 $63.92 $0.00
Supplies $0.00 $461.49 $0.00 $0.00
Food & Beverage $0.00 $0.00 $2,991.06 $0.00
Food & Beverage $0.00 $0.00 -$38.68 $0.00
Food & Beverage $0.00 $0.00 -$38.39 $0.00
Food & Beverage $0.00 $0.00 $5.98 $0.00
Contract Services $200.50 $0.00 $0.00 $0.00
Food & Beverage $0.00 $0.00 $54.42 $0.00
Food & Beverage $0.00 $0.00 -$124.30 $0.00
Food & Beverage $0.00 $0.00 $595.64 $0.00
Food & Beverage $0.00 $0.00 $968.88 $0.00
Supplies $0.00 $400.04 $0.00 $0.00
Food & Beverage $0.00 $0.00 $3,251.62 $0.00
Food & Beverage $0.00 $0.00 $543.24 $0.00
Food & Beverage $0.00 $0.00 $75.66 $0.00
Food & Beverage $0.00 $0.00 $137.28 $0.00
Food & Beverage $0.00 $0.00 $9.70 $0.00
Supplies $0.00 $243.10 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
 $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$1,841.30 $7,641.58 $52,918.52 $0.00
 BUDGET $68,000.00

.
Total Invoice Monthly Budget
Uniforms Amount Remaining
$0.00 $468.98 $67,531.02
$0.00 $124.24 $67,406.78
$0.00 $61.30 $67,345.48
$0.00 $598.77 $66,746.71
$0.00 $108.54 $66,638.17
$0.00 $298.24 $66,339.93
$0.00 $4,559.55 $61,780.38
$0.00 $437.76 $61,342.62
$0.00 $128.96 $61,213.66
$0.00 $168.95 $61,044.71
$0.00 $528.42 $60,516.29
$0.00 $170.79 $60,345.50
$0.00 $22.30 $60,323.20
$0.00 $3,465.26 $56,857.94
$0.00 $520.50 $56,337.44
$0.00 $4,164.32 $52,173.12
$0.00 $46.91 $52,126.21
$0.00 $10.67 $52,115.54
$0.00 $174.12 $51,941.42
$0.00 $175.00 $51,766.42
$0.00 $64.70 $51,701.72
$0.00 $57.89 $51,643.83
$0.00 -$19.62 $51,663.45
$0.00 $500.55 $51,162.90
$0.00 $370.36 $50,792.54
$0.00 $83.70 $50,708.84
$0.00 $39.57 $50,669.27
$0.00 $519.01 $50,150.26
$0.00 $315.10 $49,835.16
$0.00 $4,752.34 $45,082.82
$0.00 $134.56 $44,948.26
$0.00 $74.00 $44,874.26
$0.00 $93.17 $44,781.09
$0.00 $2,492.49 $42,288.60
$0.00 $474.66 $41,813.94
$0.00 $845.71 $40,968.23
$0.00 $4,014.19 $36,954.04
$0.00 $155.65 $36,798.39
$0.00 $967.80 $35,830.59
$0.00 $175.00 $35,655.59
$0.00 $68.73 $35,586.86
$0.00 $489.70 $35,097.16
$0.00 $3,586.04 $31,511.12
$0.00 $586.89 $30,924.23
$0.00 $5.99 $30,918.24
$0.00 $111.54 $30,806.70
$0.00 $138.76 $30,667.94
$0.00 $240.63 $30,427.31
$0.00 $25.73 $30,401.58
$0.00 $307.54 $30,094.04
$0.00 $440.47 $29,653.57
$0.00 $16.11 $29,637.46
$0.00 $537.18 $29,100.28
$0.00 $4,315.12 $24,785.16
$0.00 $700.50 $24,084.66
$0.00 $111.93 $23,972.73
$0.00 $60.86 $23,911.87
$0.00 $97.26 $23,814.61
$0.00 $44.94 $23,769.67
$0.00 $145.32 $23,624.35
$0.00 $536.86 $23,087.49
$0.00 $175.00 $22,912.49
$0.00 $435.76 $22,476.73
$0.00 $929.68 $21,547.05
$0.00 $4,006.81 $17,540.24
$0.00 $406.03 $17,134.21
$0.00 $425.20 $16,709.01
$0.00 $121.52 $16,587.49
$0.00 $83.19 $16,504.30
$0.00 $252.35 $16,251.95
$0.00 $74.00 $16,177.95
$0.00 $15.92 $16,162.03
$0.00 $21.97 $16,140.06
$0.00 $63.64 $16,076.42
$0.00 -$8.55 $16,084.97
$0.00 $240.53 $15,844.44
$0.00 $192.15 $15,652.29
$0.00 $88.78 $15,563.51
$0.00 $163.75 $15,399.76
$0.00 $63.92 $15,335.84
$0.00 $461.49 $14,874.35
$0.00 $2,991.06 $11,883.29
$0.00 -$38.68 $11,921.97
$0.00 -$38.39 $11,960.36
$0.00 $5.98 $11,954.38
$0.00 $200.50 $11,753.88
$0.00 $54.42 $11,699.46
$0.00 -$124.30 $11,823.76
$0.00 $595.64 $11,228.12
$0.00 $968.88 $10,259.24
$0.00 $400.04 $9,859.20
$0.00 $3,251.62 $6,607.58
$0.00 $543.24 $6,064.34
$0.00 $75.66 $5,988.68
$0.00 $137.28 $5,851.40
$0.00 $9.70 $5,841.70
$0.00 $243.10 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $0.00 $5,598.60
$0.00 $62,401.40 $5,598.60
Invoice/Credit #1

Item Description Amount

CSUPP Supplemental Labor 9,101.92

RTLSPLIT Retail Sales - 50% Split 4,855.82
Total ###

Invoice/Credit #2

Item Description Amount

Total 0.00

Invoice/Credit #3

Item Description Amount

Total 0.00
Description

Description

Description
PC 741 - Affinity Medical Center

HHS & CHS COLLECTS

Sales Tax Rate: 6.50% Gross Collections
Item Amount Tax** Net HHS CHS
Cash 8,370.04 510.85 7,859.19 8,370.04 -
Credit Cards 3,830.26 233.77 3,596.49 3,830.26 -
PR Deduct 19,949.74 1,217.59 18,732.15 - 19,949.74

32,150.04 1,962.21 30,187.83 12,200.30 19,949.74

Invoice/(Credit) the Facility 4,855.82 (4,855.82)

50/50 Split 17,056.12 15,093.92

Tax to be Remitted to Appropriate Authority (1,962.21)

Net cash realized 15,093.92 15,093.92

* Assumes HHS collects and pays all sales tax liability

 10/1/2017

50/50 Split of net

HHS CHS Total
3,929.60 3,929.60 7,859.19
1,798.24 1,798.24 3,596.49
9,366.08 9,366.08 18,732.15

15,093.92 15,093.92 30,187.83