STATE OF WASHINGTON DIVISION OF DEVELOPMENTAL DISABILITIES RESIDENTIAL SUPPORT PROGRAMS COST REPORT GENERAL INFORMATION AND CERTIFICATION

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1 SCHEDULE A DIVISION OF DEVELOPMENTAL DISABILITIES COST REPORT GENERAL INFORMATION AND CERTIFICATION PART A - PROVIDER IDENTIFYING INFORMATION 1. PROVIDER AGENCY NAME 2. PROVIDER (SSPS) No.(s) 825, PROVIDER MAILING ADDRESS 4. CITY, ZIP 5. PROVIDER PHONE NUMBER 233 Sixth Ave N. Seattle, ADMINISTRATOR 7. ADDRESS 8. DDD REGION NUMBER Sylvia Fuerstenberg sylvia@arcofkingcounty.org 2 9. HOME OFFICE/CORPORATE NAME (please indicate if NONE or SAME AS ABOVE) same as above 10. HOME OFFICE MAILING ADDRESS 11. CITY AND ZIP 12. HOME OFFICE PHONE No. 13. COST REPORT PREPARER 14. FIRM NAME Wendy Harnos 15. REPORT CONTACT INDIVIDUAL(S) 16. CONTACT PHONE # 17. CONTACT Address Wendy Harnos wendy@arcofkingcounty.org 18. COST REPORT PERIOD 19. REPORTING PURPOSE PART B. - CERTIFICATION 1/1/ /31/2011 FROM: TO: Cost Report Budget MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER STATE OR FEDERAL LAW CERTIFICATION I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying cost report and supporting schedules prepared for: (Provider Name) and to the best of my knowledge and belief, it is a true, correct and complete statement prepared in accordance with applicable instructions, except as noted. SIGNATURE of PERSON SIGNING PROVIDER FEDERAL INCOME TAX RETURN Executive Director TITLE DATE DSHS/DDD Schedule A, Page 1 (Rev. 12/04)

2 SCHEDULE B PROGRAM INFORMATION 1 ARE MEDICAL SERVICES PURCHASED OR PROVIDED FOR DEVELOPMENTAL DISABILITIES CONTRACTS? Yes No If Yes, include cost of services in Schedule E, line for Medical Services Staff Salaries and Wages, or Direct Care Purchased Services. 2 PLEASE INDICATE YOUR TYPE OF BUSINESS Individual Partnership Proprietary Corporation Non-Profit Corporation Government Agency 3 PLEASE INDICATE THE ACCOUNTING BASIS USED: Cash Accrual Modified Cash 4 ALLOCATION OF SHARED COSTS a Does your agency operate multiple programs contracted with DDD, e.g., Supported Living and Group Homes, or a combination of DDD and other contracts? Yes No b If yes to question 4a, do you allocate administrative and program overhead costs? Yes No c d What is your agency's method of allocating costs? ISS Paid Hours Worked Other Method If you answered 'Yes" to questions 4a and 4b, and you use ISS Hours Worked as your allocation method, use Schedule C, allocation rows to allocate costs. If you use another allocation method or do not allocate costs, enter your costs on schedule C in the direct cost rows. PAID WORKED (a) (b) (c) (d) (e) (f) (g) (h) (i) PROGRAM NAME * PROVIDER (SSPS) NUMBER * PROGM TYPE (SL, GH, SSP, ETC.) REGULAR ISS WORKED SLEEP CALL-BACK TOTAL PAID WORKED (d+e+f) ANNUAL RESIDENT DAYS AVERAGE PER RESIDENT DAY 1 A Supported Living Program SL 68,576 68,576 B SSP SSP C 0 D 0 E 0 F 0 G 0 Post total of column G (for Programs Subject to Settlement) to Schedule J, line , ,888 0 ** Hours associated with SSP, excluded in Line 24 of Schedule J. (DSHS/DDD SCHEDULE B-(REV)12/05) * Post to Corresponding Columns on Schedule D

3 Total Total Total Enter data on Schedule C. This sheet sums the allocated and non-allocated costs. SCHEDULE C ADMIN. & OPERATIONS COSTS Program SL SSP Prov. No TOTAL PAID WORKED* 68, , % OF TOTAL PAID WORKED 10% 99.55% 0.45% % % % % % 3 ADMIN. & OTHER NON-ISS STAFF H O U R S ADMINISTRATOR 1,04 1, PROGRAM MANAGEMENT ACCOUNTING/BOOKKEEPING 1,04 1, MAINTENANCE OTHER NON-ISS STAFF ADMINISTRATIVE EXPENSE D O L L A R S 5411 Administrative Salaries and Wages $117, $117, $ $ $ $ $ $ 5412 Administrative Benefits & PR Taxes $26, $26, $ $ $ $ $ $ 5414 Purchased Professional Services $50, $50, $ $ $ $ $ $ 5417 Management Fees $ $ $ $ $ $ $ $ 4 TOTAL ADMINISTRATIVE EXPENSE $194, $194, $ $ $ $ $ $ PROGRAM OPERATIONS EXPENSE 5413 Administrative Supplies $7, $7, $ $ $ $ $ $ Administrative Travel Expenses (mileage, 5516 lodging, public transportation) $ $ $ $ $ $ $ $ 5431 Advertising Expense $ $ $ $ $ $ $ $ 5426 Professional Liability Insurance $3, $3, $ $ $ $ $ $ 5439 Other General Admin. Expense $9, $9, $ $ $ $ $ $ 5 TOTAL ADMINISTRATIVE EXPENSE $21, $21, $ $ $ $ $ $ CAPITAL & PROPERTY EXPENSE 53*0 Depreciation - Land Improvements, Buildings, Building Imp., Leasehold Impr., Furn. & Equip. (Detail on Schedule F) $7, $7, $ $ $ $ $ $ 5423 Communications Expense $18, $18, $ $ $ $ $ $

4 Total Total Enter data on Schedule C. This sheet sums the allocated and non-allocated costs. SCHEDULE C ADMIN. & OPERATIONS COSTS Program SL SSP Prov. No Facility Insurance Expense $7, $7, $ $ $ $ $ $ 5380 Office Rent Expense $57, $57, $ $ $ $ $ $ 5380 Lease Payments Expense $2, $2, $ $ $ $ $ $ 5481 Utilities Expense $3, $3, $ $ $ $ $ $ 5483 Property Taxes $ $ $ $ $ $ $ $ 5486 Minor Equipment Expense $4, $4, $ $ $ $ $ $ 5487 Other Property Expense $4, $4, $ $ $ $ $ $ 6 TOTAL PROPERTY EXPENSE $107, $107, $ $ $ $ $ $ INTEREST & TAX EXPENSE Working Capital, Property, Line of Credit 5421, 5Debt Expense (Detail on Schedule G) $ $ $ $ $ $ $ $ 5428 Business Taxes (Does not include portion of B & O tax charged as ISS Payroll Tax) $ $ $ $ $ $ $ $ 7 TOTAL INTEREST & TAXES EXPENSE $ $ $ $ $ $ $ $ 8 TOTALS $323, $323, $ $ $ $ $ $ To Schedule E To Schedule E To Schedule E To Schedule E To Schedule E To Schedule E To Schedule E Col. A, Line 1 Col. B, Line 1 Col. C, Line 1 Col. D, Line 1 Col. E, Line 1 Col. F, Line 1 Col. G, Line 1 (DSHS/DDD SCHEDULE C-SUM 10/08) *From Schedule B

5 10/11/ Arc of King County Cost Report rev, E Page 1of 2 SCHEDULE E PROGRAMS SL SSP PROVIDER NUMBER TOTAL PROGRAM COSTS TOTALS ALLOCATED EXPENSES (from Schedule C - 1 Line 8) $323, $323, $ $ $ $ $ $ DIRECT CARE STAFF COMPENSATION a 5611 Direct Staff Salaries and Wages $905, $898, $6, $ $ $ $ $ b 5611 Medical Services Staff Salaries and Wages $ $ $ $ $ $ $ $ c 5612 Dir. & Medical Staff Fringe and PR Taxes $196, $196, $ $ $ $ $ $ d 5614 Direct Care Purchased Services $8, $8, $ $ $ $ $ $ e 5612 Staff Lodging Expenses - Supt. Living Only (cost of primary dwelling for ISS personnel paid for by the agency as part of their compensation package) $ $ $ $ $ $ $ $ 3 TOTAL DIRECT CARE STAFF COMP. $1,110, $1,104, $6, $ $ $ $ $ a 5611 Admin. Direct Care Salaries & Wages $29, $29, $ $ $ $ $ $ b 5612 Admin. Dir. Care Benefits/PR Taxes $4, $4, $ $ $ $ $ $ 4 TOTAL ADMIN. STAFF DIRECT CARE COMP. $34, $34, $ $ $ $ $ $ a ADMIN. STAFF DIRECT CARE COMPENSATION OTHER CLIENT RELATED EXPENSES Overnight Staff Coverage Lodging Expenses(housing units provided for onduty staff - not primary dwelling for staff): Not ISS $ $ $ $ $ $ $ $ b 5211 Food costs - Resident (Group Homes primarily) $ $ $ $ $ $ $ $ c 5212 Food costs - Staff $ $ $ $ $ $ $ $ d 5425 Education and In-Service Training & Supplies $2, $2, $ $ $ $ $ $ e 5435 Activities and Habilitative Supplies & other Expenses $1, $1, $ $ $ $ $ $

6 10/11/ Arc of King County Cost Report rev, E Page 2of 2 SCHEDULE E PROGRAMS SL SSP PROVIDER NUMBER TOTAL PROGRAM COSTS TOTALS f 5435 Nursing Supplies Expense $ $ $ $ $ $ $ $ TRANSPORTATION EXPENSE g 5516 Staff Mileage Reimbursement $37, $36, $1, $ $ $ $ $ h 5517 All Other Client Transportation Expense (Agency Vehicle Fuel, Maint., Depreciation; Public Trans. Etc.) $ $ $ $ $ $ $ $ MAINTENANCE/ LAUNDRY/ HOUSEKEEPING/ DIETARY i 54*1 Salaries and Wages $ $ $ $ $ $ $ $ j 54*2 Fringe Benefits and Payroll Taxes $ $ $ $ $ $ $ $ k 54*3 Supplies & Materials $ $ $ $ $ $ $ $ l 54*4 Purchased Services $ $ $ $ $ $ $ $ 5 TOTAL OTHER RESIDENT RELATED EXP. $41, $40, $1, $ $ $ $ $ 6 TOTALS (Lines 1-5) $1,510, $1,502, $7, $ $ $ $ $ 7 *PAID WORKED (FROM SCHED. B) 68,888 68, a COST PER HOUR - Admin. & Non-Staff $4.69 $4.71 $ $ $ $ $ $ 8b COST/HR - Direct Srvc & Client Related $17.24 $17.21 $24.19 $ $ $ $ $ 8c COST PER HOUR - Total Program $21.93 $21.92 $24.19 $ $ $ $ $ (DSHS/DDD SCHEDULE E - (REV) 10/2008)

7 10/11/ Arc of King County Cost Report rev, H SCHEDULE H PROGRAMS SL SSP RESIDENTIAL SERVICES REVENUE TOTALS REVENUE FOR SERVICES State Payments for DSHS Clients $1,533,210 $1,518,638 $14,572 $0 $0 $0 $0 $ DSHS Client Participation $0 $0 $0 $0 $0 $0 $0 $ Prior Years Settlements Deducted from State Payments $0 $0 $0 $0 $0 $0 $0 $ Non DSHS Client Payments $0 $0 $0 $0 $0 $0 $0 $ Other(Detail in Schedule L) $0 $0 $0 $0 $0 $0 $0 $0 6 TOTAL SERVICES REVENUE $1,533,210 $1,518,638 $14,572 $0 $0 $0 $0 $0 OTHER OPERATING REVENUES Summer Programs $0 $0 $0 $0 $0 $0 $0 $ Client Evaluation $0 $0 $0 $0 $0 $0 $0 $ Other(Detail in Schedule L) $0 $0 $0 $0 $0 $0 $0 $ Non-DSHS Revenue $255 $255 $0 $0 $0 $0 $0 $0 11 TOTAL OTHER OPERATING REV. $255 $255 $0 $0 $0 $0 $0 $0 NONOPERATING REVENUE Interest Income $0 $0 $0 $0 $0 $0 $0 $ Cash Donations & Contributions $0 $0 $0 $0 $0 $0 $0 $0 14 Noncash Donations & Contributions $0 $0 $0 $0 $0 $0 $0 $0 15 Other(Detail in Schedule L) $0 $0 $0 $0 $0 $0 $0 $0 16 TOTAL NONOPERATING REVENUE $0 $0 $0 $0 $0 $0 $0 $0 TOTAL REVENUES 17 TOTAL FROM LINES 6, 11 and 16 $1,533,465 $1,518,893 $14,572 $0 $0 $0 $0 $0 DSHS/DDD SCHEDULE H (08/2001)