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A B C D E F G H I J K L M

Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Alameda LGA Alameda USD 10/11-1 2012-Q4 $ - $ - ### $ 37,303 $ 27,977 $ (9,326) 1
3 Alameda LGA Alameda USD 10/11-2 2013-Q1 $ - $ - ### $ 42,577 $ 31,933 $ (10,644) 1
4 Alameda LGA Alameda USD 10/11-3 2013-Q2 $ - $ - ### $ 54,966 $ 21,986 $ (32,980)
5 Alameda LGA Alameda USD 11/12-3 Err:520 $ 73,636 $ 29,454 $ 44,182 $ - ### $ - 3006
6 Alameda LGA Alameda USD 10/11-4 2013-Q3 $ - $ - ### $ 49,917 $ 37,438 $ (12,479) 1
7 Alameda LGA Alameda USD 11/12-4 Err:520 $ 412,557 $ 165,023 $ 247,534 $ - ### $ - 3801
8 Alameda LGA Alameda USD 11/12-1C-1 Err:520 $ 68,225 $ 27,290 $ 40,935 $ - ### $ - 1457
9 Alameda LGA Alameda USD 11/12-2C-1 Err:520 $ 47,765 $ 35,824 $ 11,941 $ - ### $ - 1 2206
10 Alameda USD Total $ 602,183 $ 257,591 $ 344,592 $ 184,763 $ 119,334 $ (65,429) $ 192,162
11 Alameda LGA Education for Change 11/12-1 Err:520 $ 28,059 $ 25,000 $ 3,059 $ - ### $ - 2 1458
12 Education for Change Total $ 28,059 $ 25,000 $ 3,059 $ - $ - $ - $ 25,000
13 Alameda LGA Hayward USD 11/12-1 Err:520 $ 115,801 $ 46,320 $ 69,481 $ - ### $ - 1459
14 Alameda LGA Hayward USD 10/11-2 2013-Q1 $ - $ - ### $ 167,864 $ 67,146 $ (100,718)
15 Alameda LGA Hayward USD 11/12-2 Err:520 $ 373,582 $ 149,433 $ 224,149 $ - ### $ - 2208
16 Alameda LGA Hayward USD 10/11-3 2013-Q2 $ - $ - ### $ 198,304 $ 79,322 $ (118,982)
17 Alameda LGA Hayward USD 11/12-3 Err:520 $ 275,366 $ 110,146 $ 165,220 $ - ### $ - 3008
18 Alameda LGA Hayward USD 10/11-4 2013-Q3 $ - $ - ### $ 218,102 $ 87,241 $ (130,861)
19 Alameda LGA Hayward USD 11/12-4 Err:520 $ 310,108 $ 124,043 $ 186,065 $ - ### $ - 3803
20 Hayward USD Total $ 1,074,857 $ 429,942 $ 644,915 $ 584,270 $ 233,709 $ (350,561) $ 79,381
21 Alameda LGA Oakland USD 10/11-1 2012-Q4 $ - $ - ### $ 244,337 $ 97,735 $ (146,602)
22 Alameda LGA Oakland USD 11/12-1 Err:520 $ 304,244 $ 121,698 $ 182,546 $ - ### $ - 1460
23 Alameda LGA Oakland USD 10/11-2 2013-Q1 $ - $ - ### $ 314,486 $ 125,794 $ (188,692)
24 Alameda LGA Oakland USD 11/12-2 Err:520 $ 369,632 $ 147,853 $ 221,779 $ - ### $ - 2209
25 Alameda LGA Oakland USD 10/11-3 2013-Q2 $ - $ - ### $ 311,814 $ 124,726 $ (187,088)
26 Alameda LGA Oakland USD 11/12-3 Err:520 $ 384,697 $ 153,879 $ 230,818 $ - ### $ - 3009
27 Alameda LGA Oakland USD 10/11-4 2013-Q3 $ - $ - ### $ 361,151 $ 144,460 $ (216,691)
28 Alameda LGA Oakland USD 11/12-4 Err:520 $ 460,608 $ 184,243 $ 276,365 $ - ### $ - 3804
29 Alameda LGA Oakland USD 12/13-1 Err:520 $ 291,494 $ 116,598 $ 174,896 $ - ### $ - 4576
30 Alameda LGA Oakland USD 12/13-2 Err:520 $ 375,485 $ 150,194 $ 225,291 5345
31 Oakland USD Total Err:502 Err:502 Err:502 $ 1,231,788 $ 492,715 $ (739,073) Err:502
32 Grand Total Alameda LGA Err:502 Err:502 Err:502 $ 2,000,821 $ 845,758 $ (1,155,063) Err:502
33
34
35 Column A County - Reporting LEC/LGA
36 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
37 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
38 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
39 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
40 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
41 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
42 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
43 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
44 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
45 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
46 The last subtotal amount is the final amount due to/from the LEC/LGA
47 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
48

49 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
50 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
51 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
52

53 Released Claiming Unit Invoice on placeholder to be paid 100%


54

55 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
56 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
57

58 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
59 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
60 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
61 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
62

63 Claiming units no longer participating (5% reduction)


64
65 12/13 claims
66 13/14 claims
A B C D E F G H I J K L M N O P Q R S T U

1
Pro-Rata Net Negative Distribution Table

2
Total amount
Amount to be recouped Amount to withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + release to 2013 and CUs in Option (insert 1 City College of San
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit Red) or 2) Brentwood Union SD Francisco Martinez USD Redwood City ESD Sequoia UHSD Travis USD
3 Contra Costa Alameda COE 10/11-3 2013-Q2 $ - $ - ### $ 25,449 $ 25,000 $ (449) 2
4 Contra Costa Alameda COE 12/13-1 Err:520 $ 7,486 $ 6,737 $ 749
5 Alameda COE Total $ 7,486 $ 6,737 $ 749 $ 25,449 $ 25,000 $ (449) $ 6,288 0.35% Err:502 Err:502 $ 261.43 $ 520.45 $ 0.83 $ 217.30 $ 651.17 $ 33.61
6 Contra Costa Antioch USD 11/12-1 2013-Q4 $ - $ - ### $ 89,963 $ 35,985 $ (53,978)
7 Contra Costa Antioch USD 11/12-2 2014-Q1 $ - $ - ### $ 68,376 $ 27,350 $ (41,026)
8 Contra Costa Antioch USD 11/12-3 Err:520 $ 129,708 $ 51,883 $ 77,825 $ - ### $ -
9 Contra Costa Antioch USD 10/11-4 2013-Q3 $ - $ - ### $ 40,151 $ 30,113 $ (10,038) 2
10 Contra Costa Antioch USD 11/12-4C-1 Err:520 $ 95,577 $ 38,231 $ 57,346 $ - ### $ -
11 Contra Costa Antioch USD 12/13-1 Err:520 $ 20,697 $ 18,627 $ 2,070
12 Antioch USD Total $ 245,982 $ 108,741 $ 137,241 $ 198,490 $ 93,448 $ (105,042) $ 3,699 0.20% Err:502 Err:502 $ 153.79 $ 306.16 $ 0.49 $ 127.83 $ 383.06 $ 19.77
13 Contra Costa Brentwood Union SD 10/11-1 2012-Q4 $ - $ - ### $ 263,526 $ 105,410 $ (158,116)
14 Contra Costa Brentwood Union SD 11/12-1 Err:520 $ 296,279 $ 118,512 $ 177,767 $ - ### $ -
15 Contra Costa Brentwood Union SD 10/11-2 2013-Q1 $ - $ - ### $ 185,936 $ 74,374 $ (111,562)
16 Contra Costa Brentwood Union SD 11/12-2 Err:520 $ 220,089 $ 88,036 $ 132,053 $ - ### $ -
17 Contra Costa Brentwood Union SD 10/11-3 2013-Q2 $ - $ - ### $ 342,795 $ 137,118 $ (205,677)
18 Contra Costa Brentwood Union SD 11/12-3 Err:520 $ 326,386 $ 130,554 $ 195,832 $ - ### $ -
19 Contra Costa Brentwood Union SD 10/11-4 2013-Q3 $ - $ - ### $ 232,460 $ 92,984 $ (139,476)
20 Contra Costa Brentwood Union SD 11/12-4C-1 Err:520 $ 101,510 $ 40,604 $ 60,906 $ - ### $ -
21 Contra Costa Brentwood Union SD 12/13-1 Err:520 $ 51,978 $ 20,791 $ 31,187
22 Contra Costa Brentwood Union SD 12/13-2 Err:520 $ 52,114 $ 20,846 $ 31,268
23 Contra Costa Brentwood Union SD 12/13-3 Err:520 $ 50,552 $ 20,221 $ 30,331
24 Contra Costa Brentwood Union SD 13/14-1 Err:520 $ 9,158 $ 8,242 $ 916
25 Contra Costa Brentwood Union SD 13/14-2 Err:520 $ 30,468 $ 22,851 $ 7,617
26 Contra Costa Brentwood Union SD 13/14-3 Err:520 $ 24,475 $ 22,028 $ 2,447
27 Contra Costa Brentwood Union SD 13/14-4 Err:520 $ 13,610 $ 12,249 $ 1,361
28 Contra Costa Brentwood Union SD 12/13-4 Err:520 $ 45,989 $ 34,492 $ 11,497
29 Brentwood Union SD Total $ 1,222,608 $ 539,426 $ 683,182 $ 1,024,717 $ 409,886 $ (614,831) $ (75,405) 15.52%
30 Contra Costa Byron Union ESD 11/12-1 Err:520 $ 61,220 $ 21,427 $ 39,793 $ - ### $ -
31 Contra Costa Byron Union ESD 11/12-2 Err:520 $ 25,551 $ 17,886 $ 7,665 $ - ### $ -
32 Contra Costa Byron Union ESD 11/12-3 Err:520 $ 33,637 $ 23,546 $ 10,091 $ - ### $ -
33 Byron Union ESD Total $ 120,408 $ 62,859 $ 57,549 $ - $ - $ - $ 62,859 3.47% Err:502 Err:502 $ 2,613.40 $ 5,202.79 $ 8.25 $ 2,172.27 $ 6,509.48 $ 336.01
34 Contra Costa Cabrillo USD 10/11-2 2013-Q1 $ - $ - ### $ 34,653 $ 25,990 $ (8,663) 2
35 Contra Costa Cabrillo USD 10/11-3 2013-Q2 $ - $ - ### $ 31,310 $ 25,000 $ (6,310) 2
36 Contra Costa Cabrillo USD 10/11-4 Err:520 $ 28,873 $ 25,000 $ 3,873 $ - ### $ - 2
37 Cabrillo USD Total $ 28,873 $ 25,000 $ 3,873 $ 65,963 $ 50,990 $ (14,973) $ 10,027 0.55% Err:502 Err:502 $ 416.88 $ 829.93 $ 1.32 $ 346.51 $ 1,038.36 $ 53.60
38 Contra Costa Castro Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 26,684 $ 25,000 $ (1,684) 2
39 Contra Costa Castro Valley USD 11/12-2 Err:520 $ 36,544 $ 27,408 $ 9,136 $ - ### $ - 2
40 Castro Valley USD Total $ 36,544 $ 27,408 $ 9,136 $ 26,684 $ 25,000 $ (1,684) $ 25,724 1.42% Err:502 Err:502 $ 1,069.49 $ 2,129.16 $ 3.38 $ 888.97 $ 2,663.90 $ 137.51
41 Contra Costa Chabot College 11/12-2 Err:520 $ 29,057 $ 20,340 $ 8,717 $ - ### $ -
42 Contra Costa Chabot College 11/12-3 Err:520 $ 25,057 $ 17,540 $ 7,517 $ - ### $ -
43 Contra Costa Chabot College 11/12-4 Err:520 $ 28,688 $ 20,082 $ 8,606 $ - ### $ -
44 Chabot College Total $ 82,802 $ 57,962 $ 24,840 $ - $ - $ - $ 57,962 3.20% Err:502 Err:502 $ 2,409.81 $ 4,797.47 $ 7.61 $ 2,003.04 $ 6,002.36 $ 309.83
45 Contra Costa City College of San Francisco 10/11-1 2012-Q4 $ - $ - ### $ 212,190 $ 74,267 $ (137,923)
46 Contra Costa City College of San Francisco 11/12-1 Err:520 $ 261,968 $ 91,689 $ 170,279 $ - ### $ -
47 Contra Costa City College of San Francisco 10/11-2 2013-Q1 $ - $ - ### $ 184,822 $ 64,688 $ (120,134)
48 Contra Costa City College of San Francisco 11/12-2 Err:520 $ 180,536 $ 63,188 $ 117,348 $ - ### $ -
49 Contra Costa City College of San Francisco 10/11-3 2013-Q2 $ - $ - ### $ 210,619 $ 73,717 $ (136,902)
50 Contra Costa City College of San Francisco 11/12-3 Err:520 $ 180,050 $ 63,018 $ 117,032 $ - ### $ -
51 Contra Costa City College of San Francisco 10/11-4 2013-Q3 $ - $ - ### $ 200,022 $ 70,008 $ (130,014)
52 Contra Costa City College of San Francisco 11/12-4 Err:520 $ 154,897 $ 54,214 $ 100,683 $ - ### $ -
53 Contra Costa City College of San Francisco 12/13-1 Err:520 $ 54,665 $ 19,133 $ 35,532
54 Contra Costa City College of San Francisco 12/13-2 Err:520 $ 19,970 $ 19,970 $ -
55 Contra Costa City College of San Francisco 12/13-3 Err:520 $ 19,043 $ 19,043 $ -
56 Contra Costa City College of San Francisco 13/14-1 Err:520 $ 4,318 $ 4,318 $ -
57 Contra Costa City College of San Francisco 13/14-2 Err:520 $ 6,038 $ 6,038 $ -
58 Contra Costa City College of San Francisco 13/14-3 Err:520 $ 10,568 $ 10,568 $ -
59 Contra Costa City College of San Francisco 13/14-4 Err:520 $ 3,942 $ 3,942 $ -
60 Contra Costa City College of San Francisco 12/13-4 Err:520 $ 19,735 $ 19,735 $ -
61 City College of San Francisco Total $ 915,730 $ 374,856 $ 540,874 $ 807,653 $ 282,680 $ (524,973) $ (150,117) 30.89%
62 Contra Costa Contra Costa COE - SELPA 10/11-3 2013-Q2 $ - $ - ### $ 31,494 $ 25,000 $ (6,494) 2
63 Contra Costa Contra Costa COE - SELPA 11/12-3 Err:520 $ 28,494 $ 25,000 $ 3,494 $ - ### $ - 2
64 Contra Costa Contra Costa COE - SELPA 11/12-4 Err:520 $ 27,133 $ 25,000 $ 2,133 $ - ### $ - 2
65 Contra Costa COE - SELPA Total $ 55,627 $ 50,000 $ 5,627 $ 31,494 $ 25,000 $ (6,494) $ 43,506 2.40% Err:502 Err:502 $ 1,808.79 $ 3,600.96 $ 5.71 $ 1,503.48 $ 4,505.34 $ 232.56
66 Contra Costa Contra Costa COE - Student Programs 10/11-1 2012-Q4 $ - $ - ### $ 50,547 $ 20,219 $ (30,328)
67 Contra Costa Contra Costa COE - Student Programs 11/12-1 Err:520 $ 52,392 $ 20,957 $ 31,435 $ - ### $ -
68 Contra Costa Contra Costa COE - Student Programs 10/11-2 2013-Q1 $ - $ - ### $ 56,620 $ 22,648 $ (33,972)
69 Contra Costa Contra Costa COE - Student Programs 11/12-2 Err:520 $ 62,857 $ 25,143 $ 37,714 $ - ### $ -
70 Contra Costa Contra Costa COE - Student Programs 10/11-3 2013-Q2 $ - $ - ### $ 56,227 $ 22,491 $ (33,736)
71 Contra Costa Contra Costa COE - Student Programs 11/12-3 Err:520 $ 49,786 $ 37,340 $ 12,446 $ - ### $ - 2
72 Contra Costa Contra Costa COE - Student Programs 10/11-4 2013-Q3 $ - $ - ### $ 47,029 $ 35,272 $ (11,757) 2
73 Contra Costa Contra Costa COE - Student Programs 11/12-4 Err:520 $ 59,819 $ 23,928 $ 35,891 $ - ### $ -
74 Contra Costa Contra Costa COE - Student Programs 12/13-1 Err:520 $ 22,986 $ 20,687 $ 2,299
75 Contra Costa COE - Student Programs Total $ 247,840 $ 128,055 $ 119,785 $ 210,423 $ 100,630 $ (109,793) $ 18,262 1.01% Err:502 Err:502 $ 759.25 $ 1,511.53 $ 2.40 $ 631.10 $ 1,891.15 $ 97.62
76 Contra Costa Diablo Valley College 11/12-3 Err:520 $ 25,160 $ 17,612 $ 7,548 $ - ### $ -
77 Contra Costa Diablo Valley College 11/12-4 Err:520 $ 25,527 $ 17,869 $ 7,658 $ - ### $ -
78 Diablo Valley College Total $ 50,687 $ 35,481 $ 15,206 $ - $ - $ - $ 35,481 1.96% Err:502 Err:502 $ 1,475.15 $ 2,936.74 $ 4.66 $ 1,226.15 $ 3,674.30 $ 189.66
79 Contra Costa Dublin Unified SD 10/11-4 2013-Q3 $ - $ - ### $ 27,989 $ 25,000 $ (2,989) 2
80 Contra Costa Dublin Unified SD 12/13-1 Err:520 $ 2,678 $ 2,410 $ 268
81 Contra Costa Dublin Unified SD 12/13-2 Err:520 $ 3,110 $ 2,799 $ 311
82 Contra Costa Dublin Unified SD 12/13-3 Err:520 $ 4,535 $ 4,082 $ 453
83 Dublin Unified SD Total $ 10,323.00 $ 9,291.00 $ 1,032.00 $ 27,989 $ 25,000 $ (2,989) $ 6,302 0.35% Err:502 Err:502 $ 262.01 $ 521.61 $ 0.83 $ 217.78 $ 652.61 $ 33.69
84 Contra Costa Emery USD 11/12-1 Err:520 $ 30,255 $ 25,000 $ 5,255 $ - ### $ - 2
85 Contra Costa Emery USD 10/11-2 2013-Q1 $ - $ - ### $ 33,103 $ 25,000 $ (8,103) 2
86 Contra Costa Emery USD 11/12-2 Err:520 $ 82,741 $ 33,096 $ 49,645 $ - ### $ -
87 Contra Costa Emery USD 10/11-3 2013-Q2 $ - $ - ### $ 26,653 $ 25,000 $ (1,653) 2
88 Contra Costa Emery USD 11/12-3 Err:520 $ 69,691 $ 27,876 $ 41,815 $ - ### $ -
89 Contra Costa Emery USD 10/11-4 2013-Q3 $ - $ - ### $ 27,621 $ 25,000 $ (2,621) 2
90 Contra Costa Emery USD 11/12-4 Err:520 $ 72,949 $ 29,180 $ 43,769 $ - ### $ -
91 Emery USD Total $ 255,636 $ 115,152 $ 140,484 $ 87,377 $ 75,000 $ (12,377) $ 102,775 5.67% Err:502 Err:502 $ 4,272.94 $ 8,506.61 $ 13.49 $ 3,551.69 $ 10,643.05 $ 549.38
92 Contra Costa Fairfield-Suisun USD 10/11-1 2012-Q4 $ - $ - ### $ 56,342 $ 22,537 $ (33,805)
93 Contra Costa Fairfield-Suisun USD 11/12-1 Err:520 $ 97,173 $ 38,869 $ 58,304 $ - ### $ -
94 Contra Costa Fairfield-Suisun USD 10/11-2 2013-Q1 $ - $ - ### $ 126,589 $ 50,636 $ (75,953)
95 Contra Costa Fairfield-Suisun USD 11/12-2 Err:520 $ 163,338 $ 65,335 $ 98,003 $ - ### $ -
96 Contra Costa Fairfield-Suisun USD 10/11-3 2013-Q2 $ - $ - ### $ 147,645 $ 59,058 $ (88,587)
97 Contra Costa Fairfield-Suisun USD 11/12-3 Err:520 $ 125,502 $ 50,201 $ 75,301 $ - ### $ -
98 Contra Costa Fairfield-Suisun USD 10/11-4 2013-Q3 $ - $ - ### $ 149,499 $ 59,800 $ (89,699)
99 Contra Costa Fairfield-Suisun USD 11/12-4 Err:520 $ 131,997 $ 52,799 $ 79,198 $ - ### $ -
100 Contra Costa Fairfield-Suisun USD 12/13-1 Err:520 $ 55,990 $ 22,396 $ 33,594
101 Contra Costa Fairfield-Suisun USD 12/13-2 Err:520 $ 90,307 $ 36,123 $ 54,184
102 Contra Costa Fairfield-Suisun USD 12/13-3 Err:520 $ 74,414 $ 29,766 $ 44,648
103 Fairfield-Suisun USD Total $ 738,721 $ 295,489 $ 443,232 $ 480,075 $ 192,031 $ (288,044) $ 7,445 0.41% Err:502 Err:502 $ 309.53 $ 616.22 $ 0.98 $ 257.28 $ 770.98 $ 39.80
104 Contra Costa Fremont USD 10/11-1 2012-Q4 $ - $ - ### $ 62,571 $ 25,028 $ (37,543)
105 Contra Costa Fremont USD 11/12-1-C1 Err:520 $ 43,269 $ 32,452 $ 10,817 $ - ### $ -
106 Contra Costa Fremont USD 10/11-2 2013-Q1 $ - $ - ### $ 104,853 $ 41,941 $ (62,912)
107 Contra Costa Fremont USD 10/11-3 2013-Q2 $ - $ - ### $ 110,040 $ 44,016 $ (66,024)
108 Contra Costa Fremont USD 11/12-3 Err:520 $ 86,956 $ 34,782 $ 52,174 $ - ### $ -
109 Contra Costa Fremont USD 10/11-4 2013-Q3 $ - $ - ### $ 177,148 $ 70,859 $ (106,289)
A B C D E F G H I J K L M N O P Q R S T U

2
Total amount
Amount to be recouped Amount to withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + release to 2013 and CUs in Option (insert 1 City College of San
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit Red) or 2) Brentwood Union SD Francisco Martinez USD Redwood City ESD Sequoia UHSD Travis USD
110 Contra Costa Fremont USD 11/12-4 Err:520 $ 133,424 $ 53,370 $ 80,054 $ - ### $ -
111 Contra Costa Fremont USD 11/12-2C-1 Err:520 $ 91,514 $ 36,606 $ 54,908 $ - ### $ -
112 Contra Costa Fremont USD 12/13-1 Err:520 $ 27,216 $ 20,412 $ 6,804
113 Contra Costa Fremont USD 12/13-2 Err:520 $ 43,030 $ 32,273 $ 10,757
114 Contra Costa Fremont USD 12/13-3 Err:520 $ 51,648 $ 20,659 $ 30,989
115 Contra Costa Fremont USD 13/14-1 Err:520 $ 27,408 $ 20,556 $ 6,852
116 Contra Costa Fremont USD 12/13-4 Err:520 $ 71,037 $ 28,415 $ 42,622
117 Fremont USD Total $ 575,502 $ 279,525 $ 295,977 $ 454,612 $ 181,844 $ (272,768) $ 6,757 0.37% Err:502 Err:502 $ 280.93 $ 559.27 $ 0.89 $ 233.51 $ 699.73 $ 36.12
118 Contra Costa Jefferson ESD 11/12-1 Err:520 $ 56,845 $ 22,738 $ 34,107 $ - ### $ -
119 Contra Costa Jefferson ESD 10/11-2 2013-Q1 $ - $ - ### $ 71,139 $ 28,456 $ (42,683)
120 Contra Costa Jefferson ESD 11/12-2 Err:520 $ 181,411 $ 72,564 $ 108,847 $ - ### $ -
121 Contra Costa Jefferson ESD 10/11-3 2013-Q2 $ - $ - ### $ 56,752 $ 22,701 $ (34,051)
122 Contra Costa Jefferson ESD 11/12-3 Err:520 $ 97,019 $ 38,808 $ 58,211 $ - ### $ -
123 Contra Costa Jefferson ESD 10/11-4 2013-Q3 $ - $ - ### $ 41,180 $ 30,885 $ (10,295) 2
124 Contra Costa Jefferson ESD 11/12-4 Err:520 $ 112,962 $ 45,185 $ 67,777 $ - ### $ -
125 Jefferson ESD Total $ 448,237 $ 179,295 $ 268,942 $ 169,071 $ 82,042 $ (87,029) $ 92,266 5.09% Err:502 Err:502 $ 3,836.02 $ 7,636.79 $ 12.11 $ 3,188.52 $ 9,554.77 $ 493.21
126 Contra Costa Jefferson UHS 10/11-2 Err:520 $ 34,080 $ 23,856 $ 10,224 $ - ### $ -
127 Jefferson UHS Total* $ 34,080 $ 23,856 $ 10,224 $ - $ - $ - $ 23,856 1.32% Err:502 Err:502 $ 991.83 $ 1,974.54 $ 3.13 $ 824.41 $ 2,470.45 $ 127.52
128 Contra Costa Jefferson Union HS 11/12-2 Err:520 $ 30,528 $ 21,370 $ 9,158 $ - ### $ -
129 Contra Costa Jefferson Union HS 10/11-3 Err:520 $ 61,600 $ - ### $ -
130 Contra Costa Jefferson Union HS 11/12-3 Err:520 $ 35,049 $ 24,534 $ 10,515 $ - ### $ -
131 Contra Costa Jefferson Union HS 10/11-4 Err:520 $ 41,019 $ 28,713 $ 12,306 $ - ### $ -
132 Jefferson Union HS Total* $ 168,196 $ 74,617 $ 31,979 $ - $ - $ - $ 74,617 4.11% Err:502 Err:502 $ 3,102.25 $ 6,175.99 $ 9.79 $ 2,578.61 $ 7,727.10 $ 398.86
133 Contra Costa Knightsen SD 10/11-3 2013-Q2 $ - $ - ### $ 29,822 $ 25,000 $ (4,822) 2
134 Contra Costa Knightsen SD 12/13-1 Err:520 $ 6,214 $ 5,593 $ 621
135 Contra Costa Knightsen SD 12/13-2 Err:520 $ 5,716 $ 5,144 $ 572
136 Knightsen SD Total $ 11,930.00 $ 10,737.00 $ 1,193.00 $ 29,822 $ 25,000 $ (4,822) $ 5,915 0.33% Err:502 Err:502 $ 245.92 $ 489.58 $ 0.78 $ 204.41 $ 612.54 $ 31.62
137 Contra Costa Livermore Valley Joint USD 10/11-1 2012-Q4 $ - $ - ### $ 25,975 $ 25,000 $ (975) 2
138 Contra Costa Livermore Valley Joint USD 11/12-1 Err:520 $ 50,504 $ 20,202 $ 30,302 $ - ### $ -
139 Contra Costa Livermore Valley Joint USD 10/11-2 2013-Q1 $ - $ - ### $ 51,162 $ 20,465 $ (30,697)
140 Contra Costa Livermore Valley Joint USD 11/12-2 Err:520 $ 82,774 $ 33,110 $ 49,664 $ - ### $ -
141 Contra Costa Livermore Valley Joint USD 10/11-3 2013-Q2 $ - $ - ### $ 45,203 $ 33,902 $ (11,301) 2
142 Contra Costa Livermore Valley Joint USD 11/12-3 Err:520 $ 67,350 $ 26,940 $ 40,410 $ - ### $ -
143 Contra Costa Livermore Valley Joint USD 10/11-4 2013-Q3 $ - $ - ### $ 37,288 $ 27,966 $ (9,322) 2
144 Contra Costa Livermore Valley Joint USD 11/12-4 Err:520 $ 68,474 $ 27,390 $ 41,084 $ - ### $ -
145 Livermore Valley Joint USD Total $ 269,102 $ 107,642 $ 161,460 $ 159,628 $ 107,333 $ (52,295) $ 55,347 3.05% Err:502 Err:502 $ 2,301.09 $ 4,581.03 $ 7.26 $ 1,912.68 $ 5,731.56 $ 295.86
146 Contra Costa Martinez USD 10/11-3 2013-Q2 $ - $ - ### $ 25,238 $ 25,000 $ (238) 2
147 Martinez USD Total $ - $ - $ - $ 25,238 $ 25,000 $ (238) $ (238) 0.05%
148 Contra Costa Mill Valley Elm 11/12-3 Err:520 $ 64,102 $ 25,641 $ 38,461 $ - ### $ -
149 Contra Costa Mill Valley Elm 11/12-4 Err:520 $ 46,473 $ 34,855 $ 11,618 $ - ### $ - 2
150 Mill Valley Elm Total $ 110,575 $ 60,496 $ 50,079 $ - $ - $ - $ 60,496 3.34% Err:502 Err:502 $ 2,515.16 $ 5,007.21 $ 7.94 $ 2,090.61 $ 6,264.77 $ 323.38
151 Contra Costa Mt. Diablo USD 10/11-1 2012-Q4 $ - $ - ### $ 52,504 $ 52,504 $ -
152 Contra Costa Mt. Diablo USD 10/11-2 2013-Q1 $ - $ - ### $ 145,516 $ 145,516 $ -
153 Contra Costa Mt. Diablo USD 10/11-3 2013-Q2 $ - $ - ### $ 131,026 $ 131,026 $ -
154 Contra Costa Mt. Diablo USD 11/12-3 Err:520 $ 161,247 $ 161,247 $ - $ - ### $ -
155 Contra Costa Mt. Diablo USD 09/10-4 2012-Q3 $ - $ - ### $ 107,603 $ 107,603 $ -
156 Contra Costa Mt. Diablo USD 10/11-4 2013-Q3 $ - $ - ### $ 116,269 $ 116,269 $ -
157 Contra Costa Mt. Diablo USD 11/12-4C-1 Err:520 $ 114,212 $ 114,212 $ - $ - ### $ -
158 Mt. Diablo USD Total $ 275,459 $ 275,459 $ - $ 552,918 $ 552,918 $ - $ 275,459 15.19% Err:502 Err:502 $ 11,452.39 $ 22,799.53 $ 36.15 $ 9,519.28 $ 28,525.65 $ 1,472.46
159 Contra Costa Napa Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 82,227 $ 32,891 $ (49,336)
160 Contra Costa Napa Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 116,190 $ 46,476 $ (69,714)
161 Contra Costa Napa Valley USD 10/11-3 Err:520 $ 222,758 $ - ### $ -
162 Contra Costa Napa Valley USD 11/12-1 Err:520 $ 184,779 $ 73,912 $ 110,867 $ - ### $ -
163 Contra Costa Napa Valley USD 11/12-2 Err:520 $ 273,270 $ 109,308 $ 163,962 $ - ### $ -
164 Contra Costa Napa Valley USD 11/12-3 Err:520 $ 200,065 $ 80,026 $ 120,039 $ - ### $ -
165 Contra Costa Napa Valley USD 09/10-4 2012-Q3 $ - $ - ### $ 46,209 $ 34,657 $ (11,552) 2
166 Contra Costa Napa Valley USD 10/11-4 Err:520 $ 285,972 $ 114,389 $ 171,583 $ - ### $ -
167 Contra Costa Napa Valley USD 11/12-4C-1 Err:520 $ 143,052 $ 57,221 $ 85,831 $ - ### $ -
168 Napa Valley USD Total* $ 1,309,896 $ 434,856 $ 652,282 $ 244,626 $ 114,024 $ (130,602) $ 304,254 16.78% Err:502 Err:502 $ 12,649.56 $ 25,182.87 $ 39.93 $ 10,514.38 $ 31,507.57 $ 1,626.38
169 Contra Costa New Haven USD 10/11-1 2012-Q4 $ - $ - ### $ 68,676 $ 27,470 $ (41,206)
170 Contra Costa New Haven USD 11/12-1 Err:520 $ 49,373 $ 37,030 $ 12,343 $ - ### $ - 2
171 Contra Costa New Haven USD 10/11-2 2013-Q1 $ - $ - ### $ 84,246 $ 33,698 $ (50,548)
172 Contra Costa New Haven USD 11/12-2 Err:520 $ 75,203 $ 30,081 $ 45,122 $ - ### $ -
173 Contra Costa New Haven USD 10/11-3 2013-Q2 $ - $ - ### $ 117,816 $ 47,126 $ (70,690)
174 Contra Costa New Haven USD 11/12-3 Err:520 $ 133,459 $ 53,384 $ 80,075 $ - ### $ -
175 Contra Costa New Haven USD 11/12-4 Err:520 $ 113,625 $ 45,450 $ 68,175 $ - ### $ -
176 Contra Costa New Haven USD 10/11-4C-1 Err:520 $ 119,139 $ 47,656 $ 71,483 $ - ### $ -
177 New Haven USD Total $ 490,799 $ 213,601 $ 277,198 $ 270,738 $ 108,294 $ (162,444) $ 51,157 2.82% Err:502 Err:502 $ 2,126.89 $ 4,234.23 $ 6.71 $ 1,767.88 $ 5,297.66 $ 273.46
178 Contra Costa Newark USD 10/11-1 2012-Q4 $ - $ - ### $ 26,765 $ 25,000 $ (1,765) 2
179 Contra Costa Newark USD 10/11-2 2013-Q1 $ - $ - ### $ 84,736 $ 33,894 $ (50,842)
180 Contra Costa Newark USD 11/12-2 Err:520 $ 48,935 $ 36,701 $ 12,234 $ - ### $ - 2
181 Contra Costa Newark USD 10/11-3 2013-Q2 $ - $ - ### $ 73,092 $ 29,237 $ (43,855)
182 Contra Costa Newark USD 11/12-3 Err:520 $ 27,544 $ 25,000 $ 2,544 $ - ### $ - 2
183 Contra Costa Newark USD 10/11-4 2013-Q3 $ - $ - ### $ 72,597 $ 29,039 $ (43,558)
184 Contra Costa Newark USD 11/12-4 Err:520 $ 29,068 $ 25,000 $ 4,068 $ - ### $ - 2
185 Contra Costa Newark USD 12/13-1 Err:520 $ 12,133 $ 10,920 $ 1,213
186 Contra Costa Newark USD 12/13-2 Err:520 $ 18,511 $ 16,660 $ 1,851
187 Contra Costa Newark USD 12/13-3 Err:520 $ 17,373 $ 15,636 $ 1,737
188 Contra Costa Newark USD 12/13-4 Err:520 $ 23,355 $ 21,020 $ 2,335
189 Newark USD Total $ 176,919 $ 150,937 $ 25,982 $ 257,190 $ 117,170 $ (140,020) $ 10,917 0.60% Err:502 Err:502 $ 453.88 $ 903.59 $ 1.43 $ 377.27 $ 1,130.53 $ 58.36
190 Contra Costa Novato USD 10/11-1 2012-Q4 $ - $ - ### $ 27,287 $ 25,000 $ (2,287) 2
191 Contra Costa Novato USD 10/11-2 2013-Q1 $ - $ - ### $ 35,228 $ 26,421 $ (8,807) 2
192 Contra Costa Novato USD 11/12-2 Err:520 $ - $ - ### $ -
193 Contra Costa Novato USD 10/11-3 2013-Q2 $ - $ - ### $ 32,712 $ 25,000 $ (7,712) 2
194 Contra Costa Novato USD 09/10-4 2012-Q3 $ - $ - ### $ 30,226 $ 25,000 $ (5,226) 2
195 Contra Costa Novato USD 10/11-4 Err:520 $ 36,798 $ 27,599 $ 9,199 $ - ### $ - 2
196 Contra Costa Novato USD 12/13-1 Err:520 $ 5,455 $ 4,910 $ 545
197 Novato USD Total $ 42,253 $ 32,509 $ 9,744 $ 125,453 $ 101,421 $ (24,032) $ 8,477 0.47% Err:502 Err:502 $ 352.44 $ 701.63 $ 1.11 $ 292.95 $ 877.85 $ 45.31
198 Contra Costa Oakley Union ESD 11/12-1 Err:520 $ 67,189 $ 23,516 $ 43,673 $ - ### $ -
199 Contra Costa Oakley Union ESD 11/12-2 Err:520 $ 48,057 $ 33,640 $ 14,417 $ - ### $ -
200 Contra Costa Oakley Union ESD 11/12-3 Err:520 $ 50,522 $ 17,683 $ 32,839 $ - ### $ -
201 Contra Costa Oakley Union ESD 11/12-4 Err:520 $ 40,928 $ 28,650 $ 12,278 $ - ### $ -
202 Oakley Union ESD Total $ 206,696 $ 103,489 $ 103,207 $ - $ - $ - $ 103,489 5.71% Err:502 Err:502 $ 4,302.62 $ 8,565.71 $ 13.58 $ 3,576.36 $ 10,716.99 $ 553.20
203 Contra Costa Pacifica ESD 11/12-2 Err:520 $ 35,120 $ 26,340 $ 8,780 $ - ### $ - 2
204 Contra Costa Pacifica ESD 11/12-3 Err:520 $ 32,556 $ 25,000 $ 7,556 $ - ### $ - 2
205 Pacifica ESD Total $ 67,676 $ 51,340 $ 16,336 $ - $ - $ - $ 51,340 2.83% Err:502 Err:502 $ 2,134.49 $ 4,249.37 $ 6.74 $ 1,774.20 $ 5,316.61 $ 274.44
206 Contra Costa Pittsburg USD 10/11-1 2012-Q4 $ - $ - ### $ 26,032 $ 25,000 $ (1,032) 2
207 Contra Costa Pittsburg USD 10/11-2 2013-Q1 $ - $ - ### $ 60,862 $ 24,345 $ (36,517)
208 Contra Costa Pittsburg USD 11/12-2 Err:520 $ 25,238 $ 25,000 $ 238 $ - ### $ - 2
209 Contra Costa Pittsburg USD 10/11-3 Err:520 $ 50,220 $ - ### $ -
210 Contra Costa Pittsburg USD 11/12-3 Err:520 $ 31,502 $ 25,000 $ 6,502 $ - ### $ - 2
211 Contra Costa Pittsburg USD 10/11-4 Err:520 $ 41,336 $ 31,002 $ 10,334 $ - ### $ - 2
212 Pittsburg USD Total $ 148,296 $ 81,002 $ 17,074 $ 86,894 $ 49,345 $ (37,549) $ 43,453 2.40% Err:502 Err:502 $ 1,806.59 $ 3,596.57 $ 5.70 $ 1,501.64 $ 4,499.85 $ 232.28
213 Contra Costa Pleasanton Unified - Horizon & Village High 10/11-2 2013-Q1 $ - $ - ### $ 28,569 $ 25,000 $ (3,569) 2
214 Contra Costa Pleasanton Unified - Horizon & Village High 11/12-2 Err:520 $ 25,298 $ 25,000 $ 298 $ - ### $ - 2
215 Contra Costa Pleasanton Unified - Horizon & Village High 10/11-3 2013-Q2 $ - $ - ### $ 50,995 $ 20,398 $ (30,597)
216 Contra Costa Pleasanton Unified - Horizon & Village High 11/12-3 Err:520 $ 44,058 $ 33,044 $ 11,014 $ - ### $ - 2
217 Contra Costa Pleasanton Unified - Horizon & Village High 10/11-4 2013-Q3 $ - $ - ### $ 54,745 $ 21,898 $ (32,847)
218 Contra Costa Pleasanton Unified - Horizon & Village High 11/12-4 Err:520 $ 54,163 $ 21,665 $ 32,498 $ - ### $ -
A B C D E F G H I J K L M N O P Q R S T U

2
Total amount
Amount to be recouped Amount to withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + release to 2013 and CUs in Option (insert 1 City College of San
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit Red) or 2) Brentwood Union SD Francisco Martinez USD Redwood City ESD Sequoia UHSD Travis USD
219 Pleasanton Unified - Horizon & Village High Total $ 123,519 $ 79,709 $ 43,810 $ 134,309 $ 67,296 $ (67,013) $ 12,696 0.70% Err:502 Err:502 $ 527.84 $ 1,050.84 $ 1.67 $ 438.75 $ 1,314.76 $ 67.87
220 Contra Costa Ravenswood City ESD 11/12-1 Err:520 $ 35,066 $ 24,546 $ 10,520 $ - ### $ -
221 Contra Costa Ravenswood City ESD 10/11-2 2013-Q1 $ - $ - ### $ 69,914 $ 24,470 $ (45,444)
222 Contra Costa Ravenswood City ESD 11/12-2 Err:520 $ 82,501 $ 28,875 $ 53,626 $ - ### $ -
223 Contra Costa Ravenswood City ESD 10/11-3 2013-Q2 $ - $ - ### $ 43,729 $ 30,610 $ (13,119) 2
224 Contra Costa Ravenswood City ESD 11/12-3 Err:520 $ 69,203 $ 24,221 $ 44,982 $ - ### $ -
225 Contra Costa Ravenswood City ESD 10/11-4 2013-Q3 $ - $ - ### $ 61,322 $ 21,463 $ (39,859)
226 Contra Costa Ravenswood City ESD 11/12-4 Err:520 $ 83,612 $ 29,264 $ 54,348 $ - ### $ -
227 Ravenswood City ESD Total $ 270,382 $ 106,906 $ 163,476 $ 174,965 $ 76,543 $ (98,422) $ 8,484 0.47% Err:502 Err:502 $ 352.73 $ 702.21 $ 1.11 $ 293.19 $ 878.58 $ 45.35
228 Contra Costa Redwood City ESD 10/11-1 2012-Q4 $ - $ - ### $ 104,428 $ 41,771 $ (62,657)
229 Contra Costa Redwood City ESD 11/12-1 Err:520 $ 42,986 $ 32,240 $ 10,746 $ - ### $ - 2
230 Contra Costa Redwood City ESD 10/11-2 2013-Q1 $ - $ - ### $ 207,588 $ 83,035 $ (124,553)
231 Contra Costa Redwood City ESD 11/12-2 Err:520 $ 111,059 $ 44,424 $ 66,635 $ - ### $ -
232 Contra Costa Redwood City ESD 10/11-3 2013-Q2 $ - $ - ### $ 144,999 $ 58,000 $ (86,999)
233 Contra Costa Redwood City ESD 11/12-3 Err:520 $ 115,001 $ 46,000 $ 69,001 $ - ### $ -
234 Contra Costa Redwood City ESD 09/10-4 2012-Q3 $ - $ - ### $ 151,180 $ 60,472 $ (90,708)
235 Contra Costa Redwood City ESD 10/11-4 2013-Q3 $ - $ - ### $ 133,351 $ 53,340 $ (80,011)
236 Contra Costa Redwood City ESD 11/12-4 Err:520 $ 59,461 $ 23,784 $ 35,677 $ - ### $ -
237 Contra Costa Redwood City ESD 12/13-1 Err:520 $ 47,515 $ 35,636 $ 11,879
238 Contra Costa Redwood City ESD 12/13-2 Err:520 $ 37,081 $ 27,811 $ 9,270
239 Contra Costa Redwood City ESD 12/13-3 Err:520 $ 42,489 $ 31,867 $ 10,622
240 Contra Costa Redwood City ESD 13/14-1 Err:520 $ 17,598 $ 15,838 $ 1,760
241 Contra Costa Redwood City ESD 13/14-2 Err:520 $ 43,785 $ 32,839 $ 10,946
242 Contra Costa Redwood City ESD 13/14-3 Err:520 $ 34,578 $ 25,934 $ 8,644
243 Contra Costa Redwood City ESD 13/14-4 Err:520 $ 43,109 $ 32,332 $ 10,777
244 Contra Costa Redwood City ESD 12/13-4 Err:520 $ 44,728 $ 33,546 $ 11,182
245 Redwood City ESD Total $ 639,390 $ 382,251 $ 257,139 $ 741,546 $ 296,618 $ (444,928) $ (62,677) 12.90%
246 Contra Costa San Leandro USD 10/11-1 2012-Q4 $ - $ - ### $ 29,908 $ 25,000 $ (4,908) 2
247 Contra Costa San Leandro USD 11/12-1 Err:520 $ 44,818 $ 33,614 $ 11,204 $ - ### $ - 2
248 Contra Costa San Leandro USD 10/11-2 2013-Q1 $ - $ - ### $ 67,716 $ 27,086 $ (40,630)
249 Contra Costa San Leandro USD 11/12-2 Err:520 $ 77,479 $ 30,992 $ 46,487 $ - ### $ -
250 Contra Costa San Leandro USD 10/11-3 2013-Q2 $ - $ - ### $ 65,202 $ 26,081 $ (39,121)
251 Contra Costa San Leandro USD 11/12-3 Err:520 $ 44,096 $ 33,072 $ 11,024 $ - ### $ - 2
252 Contra Costa San Leandro USD 10/11-4 Err:520 $ 55,721 $ 22,288 $ 33,433 $ - ### $ -
253 Contra Costa San Leandro USD 11/12-4 Err:520 $ 41,252 $ 30,939 $ 10,313 $ - ### $ - 2
254 San Leandro USD Total $ 263,366 $ 150,905 $ 112,461 $ 162,826 $ 78,167 $ (84,659) $ 66,246 3.65% Err:502 Err:502 $ 2,754.22 $ 5,483.13 $ 8.69 $ 2,289.32 $ 6,860.22 $ 354.12
255 Contra Costa San Lorenzo USD 10/11-1 2012-Q4 $ - $ - ### $ 40,291 $ 30,218 $ (10,073) 2
256 Contra Costa San Lorenzo USD 11/12-1 Err:520 $ 27,673 $ 25,000 $ 2,673 $ - ### $ - 2
257 Contra Costa San Lorenzo USD 10/11-2 2013-Q1 $ - $ - ### $ 83,398 $ 33,359 $ (50,039)
258 Contra Costa San Lorenzo USD 11/12-2 Err:520 $ 49,520 $ 37,140 $ 12,380 $ - ### $ - 2
259 Contra Costa San Lorenzo USD 10/11-3 2013-Q2 $ - $ - ### $ 93,866 $ 37,546 $ (56,320)
260 Contra Costa San Lorenzo USD 11/12-3 Err:520 $ 112,700 $ 45,080 $ 67,620 $ - ### $ -
261 Contra Costa San Lorenzo USD 10/11-4 2013-Q3 $ - $ - ### $ 72,711 $ 29,084 $ (43,627)
262 Contra Costa San Lorenzo USD 11/12-4 Err:520 $ 86,302 $ 34,521 $ 51,781 $ - ### $ -
263 Contra Costa San Lorenzo USD 12/13-1 Err:520 $ 26,315 $ 19,736 $ 6,579
264 Contra Costa San Lorenzo USD 12/13-2 Err:520 $ 42,659 $ 31,994 $ 10,665
265 San Lorenzo USD Total $ 345,169 $ 193,471 $ 151,698 $ 290,266 $ 130,207 $ (160,059) $ 33,412 1.84% Err:502 Err:502 $ 1,389.13 $ 2,765.49 $ 4.38 $ 1,154.65 $ 3,460.04 $ 178.60
266 Contra Costa San Mateo COE 10/11-1 2012-Q4 $ - $ - ### $ 70,081 $ 28,032 $ (42,049)
267 Contra Costa San Mateo COE 11/12-1 Err:520 $ 68,302 $ 27,321 $ 40,981 $ - ### $ -
268 Contra Costa San Mateo COE 10/11-2 2013-Q1 $ - $ - ### $ 111,842 $ 44,737 $ (67,105)
269 Contra Costa San Mateo COE 11/12-2 Err:520 $ 114,064 $ 45,626 $ 68,438 $ - ### $ -
270 Contra Costa San Mateo COE 10/11-3 2013-Q2 $ - $ - ### $ 96,269 $ 38,508 $ (57,761)
271 Contra Costa San Mateo COE 11/12-3 Err:520 $ 105,119 $ 42,048 $ 63,071 $ - ### $ -
272 Contra Costa San Mateo COE 09/10-4 2012-Q3 $ - $ - ### $ 61,790 $ 24,716 $ (37,074)
273 Contra Costa San Mateo COE 10/11-4 2013-Q3 $ - $ - ### $ 92,996 $ 37,198 $ (55,798)
274 Contra Costa San Mateo COE 11/12-4 Err:520 $ 109,604 $ 43,842 $ 65,762 $ - ### $ -
275 Contra Costa San Mateo COE 12/13-1 Err:520 $ 30,610 $ 22,958 $ 7,652
276 Contra Costa San Mateo COE 12/13-2 Err:520 $ 46,534 $ 34,901 $ 11,633
277 Contra Costa San Mateo COE 12/13-3 Err:520 $ 43,384 $ 32,538 $ 10,846
278 Contra Costa San Mateo COE 12/13-4 Err:520 $ 40,759 $ 30,569 $ 10,190
279 San Mateo COE Total $ 558,376 $ 279,803 $ 278,573 $ 432,978 $ 173,191 $ (259,787) $ 20,016 1.10% Err:502 Err:502 $ 832.18 $ 1,656.71 $ 2.63 $ 691.71 $ 2,072.79 $ 107.00
280 Contra Costa San Mateo Foster City 10/11-2 2013-Q1 $ - $ - ### $ 31,352 $ 25,000 $ (6,352) 2
281 Contra Costa San Mateo Foster City 11/12-2 Err:520 $ 31,641 $ 25,000 $ 6,641 $ - ### $ - 2
282 San Mateo Foster City Total $ 31,641 $ 25,000 $ 6,641 $ 31,352 $ 25,000 $ (6,352) $ 18,648 1.03% Err:502 Err:502 $ 775.30 $ 1,543.48 $ 2.45 $ 644.44 $ 1,931.13 $ 99.68
283 Contra Costa San Rafael City School 09/10-4 2012-Q3 $ - $ - ### $ 27,948 $ 27,948 $ -
284 San Rafael City School Total $ - $ - $ - $ 27,948 $ 27,948 $ - $ -
285 Contra Costa Sequoia UHSD 10/11-1 2012-Q4 $ - $ - ### $ 82,488 $ 32,995 $ (49,493)
286 Contra Costa Sequoia UHSD 10/11-2 2013-Q1 $ - $ - ### $ 294,354 $ 117,742 $ (176,612)
287 Contra Costa Sequoia UHSD 11/12-2 Err:520 $ 69,917 $ 27,967 $ 41,950 $ - ### $ -
288 Contra Costa Sequoia UHSD 10/11-3 2013-Q2 $ - $ - ### $ 205,681 $ 82,272 $ (123,409)
289 Contra Costa Sequoia UHSD 11/12-3 Err:520 $ 36,908 $ 27,681 $ 9,227 $ - ### $ - 2
290 Contra Costa Sequoia UHSD 10/11-4 2013-Q3 $ - $ - ### $ 205,241 $ 82,096 $ (123,145)
291 Contra Costa Sequoia UHSD 11/12-4 Err:520 $ 81,951 $ 32,780 $ 49,171 $ - ### $ -
292 Contra Costa Sequoia UHSD 12/13-1 Err:520 $ 29,751 $ 22,313 $ 7,438
293 Contra Costa Sequoia UHSD 12/13-2 Err:520 $ 79,287 $ 31,715 $ 47,572
294 Contra Costa Sequoia UHSD 12/13-3 Err:520 $ 59,080 $ 23,632 $ 35,448
295 Contra Costa Sequoia UHSD 13/14-1 Err:520 $ 14,255 $ 12,830 $ 1,425
296 Contra Costa Sequoia UHSD 13/14-2 Err:520 $ 38,943 $ 29,207 $ 9,736
297 Contra Costa Sequoia UHSD 13/14-3 Err:520 $ 38,259 $ 28,694 $ 9,565
298 Contra Costa Sequoia UHSD 13/14-4 Err:520 $ 18,106 $ 16,295 $ 1,811
299 Contra Costa Sequoia UHSD 12/13-4 Err:520 $ 42,301 $ 31,726 $ 10,575
300 Sequoia UHSD Total $ 508,758 $ 284,840 $ 223,918 $ 787,764 $ 315,105 $ (472,659) $ (187,819) 38.65%
301 Contra Costa So. San Francisco USD 10/11-1 2012-Q4 $ - $ - ### $ 27,819 $ 25,000 $ (2,819) 2
302 Contra Costa So. San Francisco USD 10/11-2 2013-Q1 $ - $ - ### $ 66,144 $ 26,458 $ (39,686)
303 Contra Costa So. San Francisco USD 11/12-2 Err:520 $ 82,975 $ 33,190 $ 49,785 $ - ### $ -
304 Contra Costa So. San Francisco USD 10/11-3 2013-Q2 $ - $ - ### $ 53,040 $ 21,216 $ (31,824)
305 Contra Costa So. San Francisco USD 11/12-3 Err:520 $ 52,857 $ 21,143 $ 31,714 $ - ### $ -
306 Contra Costa So. San Francisco USD 10/11-4 2013-Q3 $ - $ - ### $ 48,272 $ 36,204 $ (12,068) 2
307 Contra Costa So. San Francisco USD 11/12-4 Err:520 $ 36,976 $ 27,732 $ 9,244 $ - ### $ - 2
308 Contra Costa So. San Francisco USD 12/13-1 Err:520 $ 2,436 $ 2,192 $ 244
309 Contra Costa So. San Francisco USD 12/13-2 Err:520 $ 16,993 $ 15,294 $ 1,699
310 So. San Francisco USD Total $ 192,237 $ 99,551 $ 92,686 $ 195,275 $ 108,878 $ (86,397) $ 13,154 0.73% Err:502 Err:502 $ 546.89 $ 1,088.75 $ 1.73 $ 454.57 $ 1,362.19 $ 70.31
311 Contra Costa Travis USD 10/11-2 2013-Q1 $ - $ - ### $ 38,781 $ 29,086 $ (9,695) 2
312 Travis USD Total $ - $ - $ - $ 38,781 $ 29,086 $ (9,695) $ (9,695) 2.00%
313 Contra Costa Vacaville USD 10/11-1 2012-Q4 $ - $ - ### $ 30,563 $ 25,000 $ (5,563) 2
314 Contra Costa Vacaville USD 11/12-1 Err:520 $ 38,071 $ 28,553 $ 9,518 $ - ### $ - 2
315 Contra Costa Vacaville USD 10/11-2 2013-Q1 $ - $ - ### $ 42,687 $ 32,015 $ (10,672) 2
316 Contra Costa Vacaville USD 11/12-2 Err:520 $ 37,239 $ 27,929 $ 9,310 $ - ### $ - 2
317 Contra Costa Vacaville USD 10/11-3 2013-Q2 $ - $ - ### $ 37,844 $ 28,383 $ (9,461) 2
318 Contra Costa Vacaville USD 11/12-3 Err:520 $ 41,365 $ 31,024 $ 10,341 $ - ### $ - 2
319 Contra Costa Vacaville USD 10/11-4 2013-Q3 $ - $ - ### $ 38,165 $ 28,624 $ (9,541) 2
320 Contra Costa Vacaville USD 11/12-4 Err:520 $ 46,576 $ 34,932 $ 11,644 $ - ### $ - 2
321 Vacaville USD Total $ 163,251 $ 122,438 $ 40,813 $ 149,259 $ 114,022 $ (35,237) $ 87,201 4.81% Err:502 Err:502 $ 3,625.44 $ 7,217.56 $ 11.44 $ 3,013.48 $ 9,030.26 $ 466.13
322 Contra Costa West Contra Costa USD 10/11-1 2012-Q4 $ - $ - ### $ 115,632 $ 46,253 $ (69,379)
323 Contra Costa West Contra Costa USD 11/12-1 Err:520 $ 134,435 $ 53,774 $ 80,661 $ - ### $ -
324 Contra Costa West Contra Costa USD 10/11-2 2013-Q1 $ - $ - ### $ 134,637 $ 53,855 $ (80,782)
325 Contra Costa West Contra Costa USD 11/12-2 Err:520 $ 178,071 $ 71,228 $ 106,843 $ - ### $ -
326 Contra Costa West Contra Costa USD 10/11-3 2013-Q2 $ - $ - ### $ 151,565 $ 60,626 $ (90,939)
327 Contra Costa West Contra Costa USD 11/12-3 Err:520 $ 157,972 $ 63,189 $ 94,783 $ - ### $ -
A B C D E F G H I J K L M N O P Q R S T U

2
Total amount
Amount to be recouped Amount to withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + release to 2013 and CUs in Option (insert 1 City College of San
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit Red) or 2) Brentwood Union SD Francisco Martinez USD Redwood City ESD Sequoia UHSD Travis USD
328 Contra Costa West Contra Costa USD 10/11-4 2013-Q3 $ - $ - ### $ 163,421 $ 65,368 $ (98,053)
329 Contra Costa West Contra Costa USD 11/12-4 Err:520 $ 176,204 $ 70,482 $ 105,722 $ - ### $ -
330 Contra Costa West Contra Costa USD 12/13-1 Err:520 $ 75,536 $ 30,214 $ 45,322
331 Contra Costa West Contra Costa USD 12/13-2 Err:520 $ 67,587 $ 27,035 $ 40,552
332 Contra Costa West Contra Costa USD 12/13-3 Err:520 $ 72,313 $ 28,925 $ 43,388
333 West Contra Costa USD Total $ 862,118 $ 344,847 $ 517,271 $ 565,255 $ 226,102 $ (339,153) $ 5,694 0.31% Err:502 Err:502 $ 236.73 $ 471.29 $ 0.75 $ 196.77 $ 589.65 $ 30.44
334 Grand Total Contra Costa LEC Err:502 Err:502 Err:502 $ 9,095,028 $ 4,437,219 $ (4,657,809) Err:502 Err:520 Err:520 Err:502 $ 75,405 $ 150,117 $ 238 $ 62,677 $ 187,819 $ 9,695
335 The sum of Column N equals the sum of "Column K" (Net Total) minus
336 the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
337 Column A County - Reporting LEC/LGA
338 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12 Pro-Rata Table
339 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Check Total Err:502 <-- Enter check total here
340 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed Sum of Net Green $ 1,813,681
341 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment Sum of Net Red $ (485,951)
342 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
343 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
344 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
345 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
346 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
347 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
348 The last subtotal amount is the final amount due to/from the LEC/LGA
349 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
350 Column N The sum of Column N equals the sum of "Column K" (Net Total) minus the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
351 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
352 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
353 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
354

355 Released Claiming Unit Invoice on placeholder to be paid 100%


356

357 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
358 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
359

360 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
361 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
362 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
363 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
364

365 Claiming units no longer participating (5% reduction)


366
367 12/13 claims
368 13/14 claims
A B C D E F G H I J K L M N O P Q R S

1 Amount to be recouped
from paid deferred
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Amount to be Released Original Paid Deferred Settlement Amount claims (Due Back to Net (Column F + Option (insert 1
County Claiming Unit FY/QTR FFY/QTR (Placehled) Placeholder Amount Placeholders Due to LEC/LGA from Placeholder Amount for Paid Deferred DHCS) Column J) or 2) Placeholder Number
2 Fresno LGA Central USD 10/11-1 2012-Q4 $ - $ - ### $ 74,641 $ 74,641 $ -
3 Fresno LGA Central USD 10/11-2 2013-Q1 $ - $ - ### $ 114,850 $ 114,850 $ -
4 Fresno LGA Central USD 09/10-4 2012-Q3 $ - $ - ### $ 77,472 $ 77,472 $ -
5 Fresno LGA Central USD 11/12-4 Err:520 $ - $ - $ - ### $ -
6 Central USD Total $ - $ - $ - $ 266,963 $ 266,963 $ - $ -
7 Fresno LGA Clovis USD 10/11-3 Err:520 $ 219,223 $ 87,689 $ 131,534 $ - ### $ - 670
8 Fresno LGA Clovis USD 10/11-1 2012-Q4 $ - $ - ### $ 190,559 $ 76,224 $ (114,335)
9 Fresno LGA Clovis USD 11/12-1 Err:520 $ 161,506 $ 64,602 $ 96,904 $ - ### $ - 1509
10 Fresno LGA Clovis USD 10/11-2 2013-Q1 $ - $ - ### $ 282,093 $ 112,837 $ (169,256)
11 Fresno LGA Clovis USD 11/12-2 Err:520 $ 255,125 $ 102,050 $ 153,075 $ - ### $ - 2258
12 Fresno LGA Clovis USD 11/12-3 Err:520 $ 186,640 $ 74,656 $ 111,984 $ - ### $ - 3060
13 Fresno LGA Clovis USD 09/10-4 2012-Q3 $ - $ - ### $ 293,830 $ 117,532 $ (176,298)
14 Fresno LGA Clovis USD 10/11-4 Err:520 $ 228,914 $ 91,566 $ 137,348 $ - ### $ - 995
15 Fresno LGA Clovis USD 11/12-4 Err:520 $ 201,381 $ 80,552 $ 120,829 $ - ### $ - 3855
16 Clovis USD Total $ 1,252,789 $ 501,115 $ 751,674 $ 766,482 $ 306,593 $ (459,889) $ 41,226
17 Fresno LGA Firebaugh-Las Deltas USD 09/10-4 2012-Q3 $ - ### $ 41,493 $ 31,120 $ (10,373) 2
18 Madera - LEC Firebaugh Las Deltas USD 12/13-1 Err:520 $ 19,641 $ 17,677 $ 1,964 4894
19 Firebaugh-Las Deltas USD Total $ 19,641 $ 17,677 $ 1,964 $ 41,493 $ 31,120 $ (10,373) $ 7,304
20 Fresno LGA Kings Canyon Joint USD 10/11-1 2012-Q4 $ - $ - ### $ 99,932 $ 39,973 $ (59,959)
21 Fresno LGA Kings Canyon Joint USD 10/11-2 2013-Q1 $ - $ - ### $ 137,153 $ 54,861 $ (82,292)
22 Fresno LGA Kings Canyon Joint USD 11/12-2 Err:520 $ 93,763 $ 37,505 $ 56,258 $ - ### $ - 2259
23 Fresno LGA Kings Canyon Joint USD 10/11-3 Err:520 $ 103,074 $ 41,230 $ 61,844 $ - ### $ - 671
24 Fresno LGA Kings Canyon Joint USD 11/12-3 Err:520 $ 92,679 $ 37,072 $ 55,607 $ - ### $ - 3061
25 Fresno LGA Kings Canyon Joint USD 09/10-4 2012-Q3 $ - $ - ### $ 114,692 $ 45,877 $ (68,815)
26 Fresno LGA Kings Canyon Joint USD 10/11-4 Err:520 $ 115,878 $ 46,351 $ 69,527 $ - ### $ - 996
27 Fresno LGA Kings Canyon Joint USD 11/12-1 Err:520 $ 78,229 $ 31,292 $ 46,937 $ - ### $ - 1465,1470,1491,1730,1732 1465 1470 1491 1730 1732
28 Fresno LGA Kings Canyon Joint USD 11/12-4 Err:520 $ 78,463 $ 31,385 $ 47,078 $ - ### $ - 3857 $ 3,061 $ 13,098 $ 3,360 $ 11,061 $ 712
29 Kings Canyon Joint USD Total $ 562,086 $ 224,835 $ 337,251 $ 351,777 $ 140,711 $ (211,066) $ 13,769
30 Fresno LGA Selma USD 11/12-1 Err:520 $ 41,816 $ 31,362 $ 10,454 $ - ### $ - 2 1510
31 Fresno LGA Selma USD 10/11-2 2013-Q1 $ - $ - ### $ 70,259 $ 28,104 $ (42,155)
32 Fresno LGA Selma USD 11/12-2 Err:520 $ 98,301 $ 39,320 $ 58,981 $ - ### $ - 2260
33 Fresno LGA Selma USD 10/11-3 2013-Q2 $ - $ - ### $ 62,680 $ 25,072 $ (37,608)
34 Fresno LGA Selma USD 11/12-3 Err:520 $ 94,374 $ 37,750 $ 56,624 $ - ### $ - 3062
35 Fresno LGA Selma USD 11/12-4C-1 Err:520 $ 106,177 $ 42,471 $ 63,706 $ - ### $ - 3855 3855
36 Fresno LGA Selma USD 10/11-4 2013-Q3 $ - $ - ### $ 65,255 $ 26,102 $ (39,153) $ 42,471
37 Selma USD Total $ 340,668 $ 150,903 $ 189,765 $ 198,194 $ 79,278 $ (118,916) $ 31,987
38 Fresno LGA West Hills Community College 10/11-1 2012-Q4 $ - $ - ### $ 139,173 $ 55,669 $ (83,504)
39 Fresno LGA West Hills Community College 11/12-1 Err:520 $ 67,434 $ 26,974 $ 40,460 $ - ### $ - 1512
40 Fresno LGA West Hills Community College 10/11-2 2013-Q1 $ - $ - ### $ 103,441 $ 41,376 $ (62,065)
41 Fresno LGA West Hills Community College 11/12-2 Err:520 $ 54,895 $ 21,958 $ 32,937 $ - ### $ - 2262
42 Fresno LGA West Hills Community College 10/11-3 Err:520 $ 86,667 $ 34,667 $ 52,000 $ - ### $ - 673
43 Fresno LGA West Hills Community College 11/12-3 Err:520 $ 65,496 $ 26,198 $ 39,298 $ - ### $ - 3064
44 Fresno LGA West Hills Community College 10/11-4 Err:520 $ 108,532 $ 43,413 $ 65,119 $ - ### $ - 1105,1123,1299 1105 1123 1299
45 Fresno LGA West Hills Community College 11/12-4 Err:520 $ 64,202 $ 25,681 $ 38,521 $ - ### $ - 3860 $ 1,454 $ 4,435 $ 37,524
46 West Hills Community College Total $ 447,226 $ 178,891 $ 268,335 $ 242,614 $ 97,045 $ (145,569) $ 33,322
47 Grand Total $ 2,622,410 $ 1,073,421 $ 1,548,989 $ 1,867,523 $ 921,710 $ (945,813) $ 127,608
48
49
50 Column A County - Reporting LEC/LGA
51 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
52 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
53 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
54 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
55 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
56 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
57 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
58 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
59 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
60 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
61 The last subtotal amount is the final amount due to/from the LEC/LGA
62 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
63

64 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
65 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
66 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
67

68 Released Claiming Unit Invoice on placeholder to be paid 100%


69

70 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
71 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
72

73 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
74 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
75 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
76 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
77

78 Claiming units no longer participating (5% reduction)


79
80 12/13 claims
81 13/14 claims
A B C D E F G H I J K L M N O P Q R S T U V W X Y

1
Pro-Rata Net Negative Distribution Table

2 Total amount
Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Amount to release to 2013 and CUs in Option (insert 1 Red Bluff Joint Union University Preparatory
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit Red) or 2) Chico USD Enterprise USD Gridley USD Orland USD Oroville Union HSD Paradise USD HSD Shasta Union HSD Trinity Alps USD School
3 Glenn Academy of Personalized Learning 09/10-2 2012-Q1 $ - $ - ### $ 26,439 $ 25,000 $ (1,439) 2
4 Glenn Academy of Personalized Learning 9/10-3 2012-Q2 $ 15,645
5 Glenn Academy of Personalized Learning 11/12-4 Err:520 $ 25,049 $ 25,000 $ 49 $ - ### $ - 2
6 Academy of Personalized Learning Total $ 40,694 $ 25,000 $ 49 $ 26,439 $ 25,000 $ (1,439) $ 23,561 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
7 Glenn Anderson Union HSD 11/12-1 Err:520 $ 68,523 $ 27,409 $ 41,114 $ - ### $ -
8 Glenn Anderson Union HSD 11/12-2 Err:520 $ 95,949 $ 38,380 $ 57,569 $ - ### $ -
9 Glenn Anderson Union HSD 11/12-3 Err:520 $ 96,926 $ 38,770 $ 58,156 $ - ### $ -
10 Glenn Anderson Union HSD 10/11-4 2013-Q3 $ - $ - ### $ 76,864 $ 30,746 $ (46,118)
11 Glenn Anderson Union HSD 11/12-4 Err:520 $ 70,753 $ 28,301 $ 42,452 $ - ### $ -
12 Anderson Union HSD Total $ 332,151 $ 132,860 $ 199,291 $ 76,864 $ 30,746 $ (46,118) $ 86,742 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
13 Glenn Butte COE 10/11-1 2012-Q4 $ - $ - ### $ 112,841 $ 45,136 $ (67,705)
14 Glenn Butte COE 9/10-3 2012-Q2 $ 152,467
15 Glenn Butte COE 11/12-1 Err:520 $ 89,035 $ 35,614 $ 53,421 $ - ### $ -
16 Glenn Butte COE 09/10-2 2012-Q1 $ - $ - ### $ 123,525 $ 49,410 $ (74,115)
17 Glenn Butte COE 10/11-2 2013-Q1 $ - $ - ### $ 132,524 $ 53,010 $ (79,514)
18 Glenn Butte COE 11/12-2 Err:520 $ 133,833 $ 53,533 $ 80,300 $ - ### $ -
19 Glenn Butte COE 10/11-3 Err:520 $ 101,803 $ 40,721 $ 61,082 $ - ### $ -
20 Glenn Butte COE 11/12-3 Err:520 $ 108,865 $ 43,546 $ 65,319 $ - ### $ -
21 Glenn Butte COE 09/10-4 2012-Q3 $ - $ - ### $ 172,698 $ 69,079 $ (103,619)
22 Glenn Butte COE 10/11-4 Err:520 $ 69,732 $ 27,893 $ 41,839 $ - ### $ -
23 Glenn Butte COE 11/12-4 Err:520 $ 62,722 $ 25,089 $ 37,633 $ - ### $ -
24 Glenn Butte COE 12/13-1 Err:520 $ 34,877 $ 26,158 $ 8,719
25 Glenn Butte COE 12/13-3 Err:520 $ 29,795 $ 22,346 $ 7,449
26 Glenn Butte COE 12/13-4 Err:520 $ 29,469 $ 22,102 $ 7,367
27 Glenn Butte COE 13/14-1 Err:520 $ 5,507 $ 4,956 $ 551
28 Glenn Butte COE 13/14-2 Err:520 $ 25,073 $ 18,805 $ 6,268
29 Glenn Butte COE 12/13-2 Err:520 $ 30,338 $ 22,754 $ 7,584
30 Butte COE Total $ 873,516 $ 343,517 $ 377,532 $ 541,588 $ 216,635 $ (324,953) $ 18,564 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
31 Glenn Cascade Union ESD 10/11-1 2012-Q4 $ - $ - ### $ 36,395 $ 27,296 $ (9,099)
32 Glenn Cascade Union ESD 11/12-1 Err:520 $ 32,313 $ 25,000 $ 7,313 $ - ### $ - 2
33 Glenn Cascade Union ESD 10/11-2 2013-Q1 $ - $ - ### $ 38,990 $ 29,243 $ (9,747)
34 Glenn Cascade Union ESD 11/12-2 Err:520 $ 40,924 $ 30,693 $ 10,231 $ - ### $ -
35 Glenn Cascade Union ESD 11/12-3 Err:520 $ 38,139 $ 28,604 $ 9,535 $ - ### $ -
36 Glenn Cascade Union ESD 09/10-4 2012-Q3 $ - $ - ### $ 47,845 $ 35,884 $ (11,961)
37 Glenn Cascade Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 31,376 $ 23,532 $ (7,844)
38 Glenn Cascade Union ESD 11/12-4 Err:520 $ 37,672 $ 28,254 $ 9,418 $ - ### $ -
39 Glenn Cascade Union ESD 10/11-3C1 Err:520 $ 30,494 $ 25,000 $ 5,494 $ - ### $ - 2
40 Cascade Union ESD Total $ 179,542 $ 137,551 $ 41,991 $ 154,606 $ 115,955 $ (38,651) $ 98,900 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
41 Glenn Chico USD 10/11-1 2012-Q4 $ - $ - ### $ 249,011 $ 99,604 $ (149,407)
42 Glenn Chico USD 11/12-1 Err:520 $ 219,156 $ 87,662 $ 131,494 $ - ### $ -
43 Glenn Chico USD 10/11-2 2013-Q1 $ - $ - ### $ 431,264 $ 172,506 $ (258,758)
44 Glenn Chico USD 11/12-2 Err:520 $ 259,886 $ 103,954 $ 155,932 $ - ### $ -
45 Glenn Chico USD 10/11-3 2013-Q2 $ - $ - ### $ 307,172 $ 122,869 $ (184,303)
46 Glenn Chico USD 11/12-3 Err:520 $ 267,521 $ 107,008 $ 160,513 $ - ### $ -
47 Glenn Chico USD 09/10-4 2012-Q3 $ - $ - ### $ 266,005 $ 106,402 $ (159,603)
48 Glenn Chico USD 10/11-4 2013-Q3 $ - $ - ### $ 227,657 $ 91,063 $ (136,594)
49 Glenn Chico USD 11/12-4 Err:520 $ 193,200 $ 77,280 $ 115,920 $ - ### $ -
50 Glenn Chico USD 12/13-1 Err:520 $ 59,216 $ 23,686 $ 35,530
51 Glenn Chico USD 12/13-2 Err:520 $ 67,029 $ 26,812 $ 40,217
52 Glenn Chico USD 12/13-3C-1 2015-Q2 $ 78,582 $ 31,433 $ 47,149
53 Glenn Chico USD 13/14-1 Err:520 $ 9,152 $ 8,237 $ 915
54 Glenn Chico USD 13/14-2 Err:520 $ 30,244 $ 22,683 $ 7,561
55 Glenn Chico USD 13/14-3 Err:520 $ 24,150 $ 21,735 $ 2,415
56 Glenn Chico USD 13/14-4 Err:520 $ 26,458 $ 19,844 $ 6,614
57 Glenn Chico USD 12/13-4 Err:520 $ 30,465 $ 22,849 $ 7,616
58 Chico USD Total $ 1,265,059 $ 553,183 $ 711,876 $ 1,481,109 $ 592,444 $ (888,665) $ (335,482) 38.09%
59 Glenn Columbia ESD 10/11-2 2013-Q1 $ - $ - ### $ 28,005 $ 25,000 $ (3,005) 2
60 Glenn Columbia ESD 11/12-2 Err:520 $ 30,861 $ 25,000 $ 5,861 $ - ### $ - 2
61 Glenn Columbia ESD 11/12-3 Err:520 $ 27,490 $ 25,000 $ 2,490 $ - ### $ - 2
62 Glenn Columbia ESD 09/10-4 2012-Q3 $ - $ - ### $ 61,406 $ 24,562 $ (36,844)
63 Glenn Columbia ESD 11/12-4 Err:520 $ 26,945 $ 25,000 $ 1,945 $ - ### $ - 2
64 Columbia ESD Total $ 85,296 $ 75,000 $ 10,296 $ 89,411 $ 49,562 $ (39,849) $ 35,151 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
65 Glenn Corning Union ESD 10/11-1 2012-Q4 $ - $ - ### $ 31,007 $ 21,705 $ (9,302)
66 Glenn Corning Union ESD 11/12-1 Err:520 $ 28,593 $ 20,015 $ 8,578 $ - ### $ -
67 Glenn Corning Union ESD 10/11-2 2013-Q1 $ - $ - ### $ 41,068 $ 28,748 $ (12,320)
68 Glenn Corning Union ESD 11/12-2 Err:520 $ 38,042 $ 26,629 $ 11,413 $ - ### $ -
69 Glenn Corning Union ESD 10/11-3 2013-Q2 $ - $ - ### $ 35,251 $ 24,676 $ (10,575)
70 Glenn Corning Union ESD 11/12-3 Err:520 $ 25,268 $ 17,688 $ 7,580 $ - ### $ -
71 Glenn Corning Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 37,084 $ 25,959 $ (11,125)
72 Glenn Corning Union ESD 11/12-4 Err:520 $ 36,449 $ 25,514 $ 10,935 $ - ### $ -
73 Corning Union ESD Total $ 128,352 $ 89,846 $ 38,506 $ 144,410 $ 101,088 $ (43,322) $ 46,524 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
74 Glenn Corning Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 37,719 $ 28,289 $ (9,430)
75 Glenn Corning Union HSD 11/12-1 Err:520 $ 32,085 $ 25,000 $ 7,085 $ - ### $ - 2
76 Glenn Corning Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 49,811 $ 37,358 $ (12,453)
77 Glenn Corning Union HSD 11/12-2 Err:520 $ 40,664 $ 30,498 $ 10,166 $ - ### $ -
78 Glenn Corning Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 44,597 $ 33,448 $ (11,149)
79 Glenn Corning Union HSD 11/12-3 Err:520 $ 38,113 $ 28,585 $ 9,528 $ - ### $ -
80 Glenn Corning Union HSD 10/11-4 2013-Q3 $ - $ - ### $ 45,130 $ 33,848 $ (11,282)
81 Glenn Corning Union HSD 11/12-4 Err:520 $ 41,356 $ 31,017 $ 10,339 $ - ### $ -
82 Corning Union HSD Total $ 152,218 $ 115,100 $ 37,118 $ 177,257 $ 132,943 $ (44,314) $ 70,786 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
83 Glenn Cottonwood Union SD 09/10-4 2012-Q3 $ - $ - ### $ 34,219 $ 25,664 $ (8,555)
84 Glenn Cottonwood Union SD 12/13-1 Err:520 $ 3,117 $ 2,805 $ 312
85 Glenn Cottonwood Union SD 12/13-2 Err:520 $ 6,999 $ 6,299 $ 700
86 Cottonwood Union SD Total $ 10,116.00 $ 9,104.00 $ 1,012.00 $ 34,219 $ 25,664 $ (8,555) $ 549 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
87 Glenn Durham USD 11/12-2 Err:520 $ 45,443 $ 34,082 $ 11,361 $ - ### $ -
88 Glenn Durham USD 10/11-3 2013-Q2 $ - $ - ### $ 33,627 $ 25,220 $ (8,407)
89 Glenn Durham USD 11/12-3 Err:520 $ 35,441 $ 26,581 $ 8,860 $ - ### $ -
90 Glenn Durham USD 10/11-4 2013-Q3 $ - $ - ### $ 27,420 $ 25,000 $ (2,420) 2
91 Glenn Durham USD 11/12-4 Err:520 $ 26,067 $ 25,000 $ 1,067 $ - ### $ - 2
92 Durham USD Total $ 106,951 $ 85,663 $ 21,288 $ 61,047 $ 50,220 $ (10,827) $ 74,836 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
93 Glenn Enterprise ESD 10/11-1 2012-Q4 $ - $ - ### $ 49,850 $ 37,388 $ (12,462)
94 Glenn Enterprise ESD 11/12-1 Err:520 $ 49,792 $ 37,344 $ 12,448 $ - ### $ -
95 Glenn Enterprise ESD 10/11-2 2013-Q1 $ - $ - ### $ 57,752 $ 23,101 $ (34,651)
96 Glenn Enterprise ESD 11/12-2 Err:520 $ 56,214 $ 22,486 $ 33,728 $ - ### $ -
97 Glenn Enterprise ESD 10/11-3 2013-Q2 $ - $ - ### $ 51,759 $ 20,704 $ (31,055)
98 Glenn Enterprise ESD 11/12-3 Err:520 $ 57,420 $ 22,968 $ 34,452 $ - ### $ -
99 Glenn Enterprise ESD 09/10-4 2012-Q3 $ - $ - ### $ 110,671 $ 44,268 $ (66,403)
100 Glenn Enterprise ESD 10/11-4 2013-Q3 $ - $ - ### $ 51,348 $ 20,539 $ (30,809)
101 Glenn Enterprise ESD 11/12-4 Err:520 $ 53,080 $ 21,232 $ 31,848 $ - ### $ -
102 Glenn Enterprise ESD 12/13-1 Err:520 $ 6,126 $ 5,513 $ 613
103 Glenn Enterprise ESD 12/13-2 Err:520 $ 9,153 $ 8,238 $ 915
104 Glenn Enterprise ESD 12/13-3 Err:520 $ 5,845 $ 5,261 $ 584
105 Glenn Enterprise ESD 13/14-1 Err:520 $ 1,889 $ 1,700 $ 189
106 Glenn Enterprise ESD 13/14-2 Err:520 $ 6,086 $ 5,477 $ 609
107 Glenn Enterprise ESD 13/14-3 Err:520 $ 5,414 $ 4,873 $ 541
108 Glenn Enterprise ESD 13/14-4 Err:520 $ 4,159 $ 3,743 $ 416
109 Glenn Enterprise ESD 12/13-4 Err:520 $ 6,332 $ 5,699 $ 633
110 Enterprise ESD Total $ 261,510 $ 144,534 $ 116,976 $ 321,380 $ 146,000 $ (175,380) $ (30,846) 3.50%
111 Glenn Evergreen Union ESD 10/11-1 2012-Q4 $ - $ - ### $ 27,052 $ 25,000 $ (2,052) 2
112 Glenn Evergreen Union ESD 11/12-1 Err:520 $ 25,261 $ 25,000 $ 261 $ - ### $ - 2
113 Glenn Evergreen Union ESD 10/11-2 2013-Q1 $ - $ - ### $ 33,188 $ 25,000 $ (8,188) 2
114 Glenn Evergreen Union ESD 11/12-2 Err:520 $ 32,197 $ 25,000 $ 7,197 $ - ### $ - 2
115 Glenn Evergreen Union ESD 10/11-3 2013-Q2 $ - $ - ### $ 33,119 $ 25,000 $ (8,119) 2
116 Glenn Evergreen Union ESD 11/12-3 Err:520 $ 36,181 $ 27,136 $ 9,045 $ - ### $ -
117 Glenn Evergreen Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 43,324 $ 32,493 $ (10,831)
118 Evergreen Union ESD Total $ 93,639.00 $ 77,136.00 $ 16,503.00 $ 136,683 $ 107,493 $ (29,190) $ 47,946 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
119 Glenn Gateway USD 10/11-1 2012-Q4 $ - $ - ### $ 105,478 $ 42,191 $ (63,287)
120 Glenn Gateway USD 11/12-1 Err:520 $ 126,154 $ 50,462 $ 75,692 $ - ### $ -
121 Glenn Gateway USD 10/11-2 2013-Q1 $ - $ - ### $ 165,537 $ 66,215 $ (99,322)
122 Glenn Gateway USD 11/12-2 Err:520 $ 151,508 $ 60,603 $ 90,905 $ - ### $ -
123 Glenn Gateway USD 10/11-3 2013-Q2 $ - $ - ### $ 175,388 $ 70,155 $ (105,233)
124 Glenn Gateway USD 11/12-3 Err:520 $ 147,543 $ 59,017 $ 88,526 $ - ### $ -
125 Glenn Gateway USD 10/11-4 2013-Q3 $ - $ - ### $ 177,869 $ 71,148 $ (106,721)
126 Glenn Gateway USD 11/12-4 Err:520 $ 154,895 $ 61,958 $ 92,937 $ - ### $ -
127 Glenn Gateway USD 12/13-1 Err:520 $ 40,516 $ 30,387 $ 10,129
128 Glenn Gateway USD 12/13-2 Err:520 $ 49,036 $ 36,777 $ 12,259
129 Glenn Gateway USD 12/13-3 Err:520 $ 41,642 $ 31,232 $ 10,410
130 Glenn Gateway USD 13/14-1 Err:520 $ 18,308 $ 16,477 $ 1,831
131 Glenn Gateway USD 13/14-2 Err:520 $ 35,522 $ 26,642 $ 8,880
A B C D E F G H I J K L M N O P Q R S T U V W X Y

2 Total amount
Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Amount to release to 2013 and CUs in Option (insert 1 Red Bluff Joint Union University Preparatory
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit Red) or 2) Chico USD Enterprise USD Gridley USD Orland USD Oroville Union HSD Paradise USD HSD Shasta Union HSD Trinity Alps USD School
132 Glenn Gateway USD 12/13-4 Err:520 $ 66,476 $ 26,590 $ 39,886
133 Gateway USD Total $ 831,600 $ 400,145 $ 431,455 $ 624,272 $ 249,709 $ (374,563) $ 25,582 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
134 Glenn Glenn COE 10/11-2 Err:520 $ 31,116 $ 23,337 $ 7,779 $ - ### $ - 1
135 Glenn Glenn COE 11/12-2 Err:520 $ 33,713 $ 25,285 $ 8,428 $ - ### $ - 1
136 Glenn Glenn COE 11/12-3 Err:520 $ 33,511 $ 25,133 $ 8,378 $ - ### $ - 1
137 Glenn Glenn COE 11/12-4 Err:520 $ 35,471 $ 26,603 $ 8,868 $ - ### $ - 1
138 Glenn COE Total $ 133,811 $ 100,358 $ 33,453 $ - $ - $ - $ 100,358 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
139 Glenn Gridley USD 10/11-1 2012-Q4 $ - $ - ### $ 34,303 $ 25,727 $ (8,576)
140 Glenn Gridley USD 10/11-2 2013-Q1 $ - $ - ### $ 62,977 $ 25,191 $ (37,786)
141 Glenn Gridley USD 11/12-2 Err:520 $ 50,637 $ 20,255 $ 30,382 $ - ### $ -
142 Glenn Gridley USD 10/11-3 2013-Q2 $ - $ - ### $ 55,522 $ 22,209 $ (33,313)
143 Glenn Gridley USD 11/12-3 Err:520 $ 40,353 $ 30,265 $ 10,088 $ - ### $ -
144 Glenn Gridley USD 09/10-4 2012-Q3 $ - $ - ### $ 124,199 $ 49,680 $ (74,519)
145 Glenn Gridley USD 10/11-4 2013-Q3 $ - $ - ### $ 46,715 $ 35,036 $ (11,679)
146 Glenn Gridley USD 11/12-4 Err:520 $ 45,197 $ 33,898 $ 11,299 $ - ### $ -
147 Glenn Gridley USD 12/13-1 Err:520 $ 7,379 $ 6,641 $ 738
148 Glenn Gridley USD 12/13-2 Err:520 $ 20,025 $ 18,023 $ 2,002
149 Glenn Gridley USD 13/14-1 Err:520 $ 5,059 $ 4,553 $ 506
150 Glenn Gridley USD 13/14-2 Err:520 $ 10,623 $ 9,561 $ 1,062
151 Glenn Gridley USD 13/14-3 Err:520 $ 7,439 $ 6,695 $ 744
152 Glenn Gridley USD 13/14-4 Err:520 $ 9,041 $ 8,137 $ 904
153 Glenn Gridley USD 12/13-4 Err:520 $ 8,842 $ 7,958 $ 884
154 Glenn Gridley USD 12/13-3 Err:520 $ 19,647 $ 17,682 $ 1,965
155 Gridley USD Total $ 224,242 $ 163,668 $ 60,574 $ 323,716 $ 157,843 $ (165,873) $ (2,205) 0.25%
156 Glenn Hamilton USD 10/11-2 Err:520 $ 29,277 $ 25,000 $ 4,277 $ - ### $ - 2
157 Glenn Hamilton USD 11/12-2 Err:520 $ 31,463 $ 25,000 $ 6,463 $ - ### $ - 2
158 Glenn Hamilton USD 09/10-3 2012-Q2 $ - $ - ### $ 36,154 $ 27,116 $ (9,038)
159 Glenn Hamilton USD 10/11-3 Err:520 $ 35,544 $ 26,658 $ 8,886 $ - ### $ -
160 Glenn Hamilton USD 11/12-3 Err:520 $ 26,704 $ 25,000 $ 1,704 $ - ### $ - 2
161 Glenn Hamilton USD 09/10-4 2012-Q3 $ - $ - ### $ 48,250 $ 36,188 $ (12,062)
162 Hamilton USD Total $ 122,988.00 $ 101,658.00 $ 21,330.00 $ 84,404 $ 63,304 $ (21,100) $ 80,558 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
163 Glenn Lassen COE 10/11-2 Err:520 $ 31,967 $ 25,000 $ 6,967 $ - ### $ - 2
164 Glenn Lassen COE 11/12-2 Err:520 $ - ### $ -
165 Glenn Lassen COE 09/10-3 2012-Q2 $ - $ - ### $ 41,160 $ 30,870 $ (10,290)
166 Glenn Lassen COE 10/11-3 Err:520 $ 29,282 $ 25,000 $ 4,282 $ - ### $ - 2
167 Glenn Lassen COE 11/12-3 Err:520 $ - $ - ### $ 30,348 $ 25,000 $ (5,348) 2
168 Glenn Lassen COE 09/10-4 2012-Q3 $ - $ - ### $ 54,464 $ 21,786 $ (32,678)
169 Glenn Lassen COE 10/11-4 Err:520 $ 30,826 $ 25,000 $ 5,826 $ - ### $ - 2
170 Glenn Lassen COE 11/12-4 Err:520 $ 35,992 $ 26,994 $ 8,998 $ - ### $ - 2
171 Lassen COE Total $ 128,067 $ 101,994 $ 26,073 $ 125,972 $ 77,656 $ (48,316) $ 53,678 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
172 Glenn Modoc COE 10/11-2 2013-Q1 $ - $ - ### $ 26,845 $ 25,000 $ (1,845) 2
173 Glenn Modoc COE 11/12-2 Err:520 $ 33,434 $ 25,076 $ 8,358 $ - ### $ -
174 Glenn Modoc COE 10/11-3 2013-Q2 $ - $ - ### $ 25,238 $ 25,000 $ (238) 2
175 Glenn Modoc COE 10/11-4 2013-Q3 $ - $ - ### $ 27,631 $ 25,000 $ (2,631) 2
176 Modoc COE Total $ 33,434.00 $ 25,076.00 $ 8,358.00 $ 79,714 $ 75,000 $ (4,714) $ 20,362 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
177 Glenn Mt. Shasta Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 30,899 $ 25,000 $ (5,899) 2
178 Glenn Mt. Shasta Union ESD 11/12-4 Err:520 $ 33,772 $ 25,329 $ 8,443 $ - ### $ - 2
179 Mt. Shasta Union ESD Total $ 33,772 $ 25,329 $ 8,443 $ 30,899 $ 25,000 $ (5,899) $ 19,430 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
180 Glenn Orland USD 09/10-1 2011-Q4 $ - $ - ### $ 118,620 $ 47,448 $ (71,172)
181 Glenn Orland USD 10/11-1 Err:520 $ 87,485 $ - ### $ -
182 Glenn Orland USD 09/10-2 2012-Q1 $ - $ - ### $ 165,020 $ 66,008 $ (99,012)
183 Glenn Orland USD 10/11-2 Err:520 $ 127,659 $ 51,064 $ 76,595 $ - ### $ -
184 Glenn Orland USD 11/12-2 Err:520 $ 104,192 $ 41,677 $ 62,515 $ - ### $ -
185 Glenn Orland USD 09/10-3 2012-Q2 $ - $ - ### $ 138,498 $ 55,399 $ (83,099)
186 Glenn Orland USD 10/11-3 Err:520 $ 114,724 $ 45,890 $ 68,834 $ - ### $ -
187 Glenn Orland USD 11/12-3 Err:520 $ 77,627 $ 31,051 $ 46,576 $ - ### $ -
188 Glenn Orland USD 09/10-4 2012-Q3 $ - $ - ### $ 146,128 $ 58,451 $ (87,677)
189 Glenn Orland USD 10/11-4 Err:520 $ 121,036 $ 48,414 $ 72,622 $ - ### $ -
190 Glenn Orland USD 12/13-1 Err:520 $ 13,622 $ 12,260 $ 1,362
191 Glenn Orland USD 12/13-2 Err:520 $ 13,552 $ 12,197 $ 1,355
192 Glenn Orland USD 12/13-3 Err:520 $ 12,865 $ 11,579 $ 1,286
193 Glenn Orland USD 13/14-1 Err:520 $ 2,176 $ 1,958 $ 218
194 Glenn Orland USD 13/14-2 Err:520 $ 5,529 $ 4,976 $ 553
195 Glenn Orland USD 13/14-3 Err:520 $ 4,564 $ 4,108 $ 456
196 Glenn Orland USD 13/14-4 Err:520 $ 4,664 $ 4,198 $ 466
197 Glenn Orland USD 12/13-4 Err:520 $ 7,829 $ 7,046 $ 783
198 Orland USD Total* $ 697,524 $ 276,418 $ 333,621 $ 568,266 $ 227,306 $ (340,960) $ (64,542) 7.33%
199 Glenn Oroville City ESD 10/11-1 2012-Q4 $ - $ - ### $ 51,282 $ 20,513 $ (30,769)
200 Glenn Oroville City ESD 11/12-1 Err:520 $ 34,151 $ 25,613 $ 8,538 $ - ### $ -
201 Glenn Oroville City ESD 10/11-2 Err:520 $ 82,103 $ 32,841 $ 49,262 $ - ### $ -
202 Glenn Oroville City ESD 11/12-2 Err:520 $ 40,827 $ 30,620 $ 10,207 $ - ### $ -
203 Glenn Oroville City ESD 11/12-3 Err:520 $ 26,735 $ 25,000 $ 1,735 $ - ### $ - 2
204 Glenn Oroville City ESD 09/10-4 2012-Q3 $ - $ - ### $ 111,731 $ 44,692 $ (67,039)
205 Glenn Oroville City ESD 10/11-4 Err:520 $ 54,190 $ 21,676 $ 32,514 $ - ### $ -
206 Glenn Oroville City ESD 10/11-3 Err:520 $ 47,283 $ 35,462 $ 11,821 $ - ### $ -
207 Oroville City ESD Total $ 285,289 $ 171,212 $ 114,077 $ 163,013 $ 65,205 $ (97,808) $ 73,404 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
208 Glenn Oroville Union HSD 11/12-1 Err:520 $ 28,539 $ 25,000 $ 3,539 $ - ### $ - 2
209 Glenn Oroville Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 31,541 $ 25,000 $ (6,541) 2
210 Glenn Oroville Union HSD 11/12-2 Err:520 $ 42,107 $ 31,580 $ 10,527 $ - ### $ -
211 Glenn Oroville Union HSD 09/10-3 2012-Q2 $ - $ - ### $ 139,853 $ 55,941 $ (83,912)
212 Glenn Oroville Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 47,230 $ 35,423 $ (11,807)
213 Glenn Oroville Union HSD 11/12-3 Err:520 $ 35,848 $ 26,886 $ 8,962 $ - ### $ -
214 Glenn Oroville Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 161,578 $ 64,631 $ (96,947)
215 Glenn Oroville Union HSD 10/11-4 2013-Q3 $ - $ - ### $ 32,164 $ 25,000 $ (7,164) 2
216 Glenn Oroville Union HSD 11/12-4 Err:520 $ 29,184 $ 25,000 $ 4,184 $ - ### $ - 2
217 Glenn Oroville Union HSD 12/13-1 Err:520 $ 17,521 $ 15,769 $ 1,752
218 Glenn Oroville Union HSD 12/13-2 Err:520 $ 22,114 $ 19,903 $ 2,211
219 Glenn Oroville Union HSD 12/13-3C-1 2015-Q2 $ 15,423 $ 13,881 $ 1,542
220 Glenn Oroville Union HSD 13/14-1 Err:520 $ 4,458 $ 4,012 $ 446
221 Glenn Oroville Union HSD 13/14-2 Err:520 $ 17,948 $ 16,153 $ 1,795
222 Glenn Oroville Union HSD 13/14-3 Err:520 $ 9,283 $ 8,355 $ 928
223 Glenn Oroville Union HSD 13/14-4 Err:520 $ 10,207 $ 9,186 $ 1,021
224 Glenn Oroville Union HSD 12/13-4 Err:520 $ 8,648 $ 7,783 $ 865
225 Oroville Union HSD Total $ 241,280 $ 203,508 $ 37,772 $ 412,366 $ 205,995 $ (206,371) $ (2,863) 0.33%
226 Glenn Palermo Union SD 10/11-1 2012-Q4 $ - $ - ### $ 45,165 $ 33,874 $ (11,291)
227 Glenn Palermo Union SD 11/12-1 Err:520 $ 36,918 $ 27,689 $ 9,229 $ - ### $ -
228 Glenn Palermo Union SD 10/11-2 2013-Q1 $ - $ - ### $ 87,581 $ 35,032 $ (52,549)
229 Glenn Palermo Union SD 11/12-2 Err:520 $ 72,161 $ 28,864 $ 43,297 $ - ### $ -
230 Glenn Palermo Union SD 10/11-3 2013-Q2 $ - $ - ### $ 72,636 $ 29,054 $ (43,582)
231 Glenn Palermo Union SD 11/12-3 Err:520 $ 69,121 $ 27,648 $ 41,473 $ - ### $ -
232 Glenn Palermo Union SD 10/11-4 2013-Q3 $ - $ - ### $ 74,986 $ 29,994 $ (44,992)
233 Glenn Palermo Union SD 11/12-4 Err:520 $ 71,601 $ 28,640 $ 42,961 $ - ### $ -
234 Glenn Palermo Union SD 12/13-1 Err:520 $ 11,332 $ 10,199 $ 1,133
235 Glenn Palermo Union SD 12/13-2 Err:520 $ 18,579 $ 16,721 $ 1,858
236 Glenn Palermo Union SD 12/13-3 Err:520 $ 22,224 $ 20,002 $ 2,222
237 Palermo Union SD Total $ 301,936 $ 159,763 $ 142,173 $ 280,368 $ 127,954 $ (152,414) $ 7,349 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
238 Glenn Paradise USD 10/11-1 2012-Q4 $ - $ - ### $ 96,010 $ 38,404 $ (57,606)
239 Glenn Paradise USD 11/12-1 Err:520 $ 72,132 $ 28,853 $ 43,279 $ - ### $ -
240 Glenn Paradise USD 10/11-2 2013-Q1 $ - $ - ### $ 94,945 $ 37,978 $ (56,967)
241 Glenn Paradise USD 11/12-2 Err:520 $ 71,284 $ 28,514 $ 42,770 $ - ### $ -
242 Glenn Paradise USD 10/11-3 2013-Q2 $ - $ - ### $ 99,871 $ 39,948 $ (59,923)
243 Glenn Paradise USD 11/12-3 Err:520 $ 66,259 $ 26,504 $ 39,755 $ - ### $ -
244 Glenn Paradise USD 10/11-4 2013-Q3 $ - $ - ### $ 70,706 $ 28,282 $ (42,424)
245 Glenn Paradise USD 11/12-4 Err:520 $ 51,027 $ 20,411 $ 30,616 $ - ### $ -
246 Glenn Paradise USD 12/13-1 Err:520 $ 17,651 $ 15,886 $ 1,765
247 Glenn Paradise USD 12/13-2 Err:520 $ 15,347 $ 13,812 $ 1,535
248 Glenn Paradise USD 13/14-1 Err:520 $ 4,229 $ 3,806 $ 423
249 Glenn Paradise USD 13/14-2 Err:520 $ 12,378 $ 11,140 $ 1,238
250 Glenn Paradise USD 13/14-3 Err:520 $ 9,016 $ 8,114 $ 902
251 Glenn Paradise USD 13/14-4 Err:520 $ 8,246 $ 7,421 $ 825
252 Glenn Paradise USD 12/13-4 Err:520 $ 8,915 $ 8,024 $ 891
253 Glenn Paradise USD 12/13-3 Err:520 $ 13,647 $ 12,282 $ 1,365
254 Paradise USD Total $ 350,131 $ 184,767 $ 165,364 $ 361,532 $ 144,612 $ (216,920) $ (32,153) 3.65%
255 Glenn Pittsburg USD 10/11-1 $ - ### $ -
256 Pittsburg USD Total $ - $ - $ - $ -
257 Glenn Plumas USD 10/11-1 2012-Q4 $ - $ - ### $ 36,187 $ 27,140 $ (9,047)
258 Glenn Plumas USD 09/10-2 2012-Q1 $ - $ - ### $ 92,404 $ 36,962 $ (55,442)
259 Glenn Plumas USD 10/11-2 Err:520 $ 56,147 $ 22,459 $ 33,688 $ - ### $ -
260 Glenn Plumas USD 11/12-2 Err:520 $ 46,429 $ 34,822 $ 11,607 $ - ### $ -
261 Glenn Plumas USD 09/10-3 2012-Q2 $ - $ - ### $ 86,852 $ 34,741 $ (52,111)
262 Glenn Plumas USD 11/12-3 Err:520 $ 39,863 $ 29,897 $ 9,966 $ - ### $ -
A B C D E F G H I J K L M N O P Q R S T U V W X Y

2 Total amount
Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Amount to release to 2013 and CUs in Option (insert 1 Red Bluff Joint Union University Preparatory
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit Red) or 2) Chico USD Enterprise USD Gridley USD Orland USD Oroville Union HSD Paradise USD HSD Shasta Union HSD Trinity Alps USD School
263 Glenn Plumas USD 09/10-4 2012-Q3 $ - $ - ### $ 84,625 $ 33,850 $ (50,775)
264 Glenn Plumas USD 10/11-4 Err:520 $ 27,628 $ 25,000 $ 2,628 $ - ### $ - 2
265 Glenn Plumas USD 11/12-4 Err:520 $ 43,169 $ 32,377 $ 10,792 $ - ### $ -
266 Glenn Plumas USD 12/13-1 Err:520 $ 13,891 $ 12,502 $ 1,389
267 Glenn Plumas USD 12/13-2 Err:520 $ 42,460 $ 31,845 $ 10,615
268 Plumas USD Total $ 269,587 $ 188,902 $ 80,685 $ 300,068 $ 132,693 $ (167,375) $ 21,527 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
269 Glenn Red Bluff Joint Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 79,590 $ 31,836 $ (47,754)
270 Glenn Red Bluff Joint Union HSD 11/12-1 Err:520 $ 86,109 $ 34,444 $ 51,665 $ - ### $ -
271 Glenn Red Bluff Joint Union HSD 09/10-2 2012-Q1 $ - $ - ### $ 127,897 $ 51,159 $ (76,738)
272 Glenn Red Bluff Joint Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 124,296 $ 49,718 $ (74,578)
273 Glenn Red Bluff Joint Union HSD 11/12-2 Err:520 $ 129,814 $ 51,926 $ 77,888 $ - ### $ -
274 Glenn Red Bluff Joint Union HSD 09/10-3 2012-Q2 $ - $ - ### $ 126,535 $ 50,614 $ (75,921)
275 Glenn Red Bluff Joint Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 117,252 $ 46,901 $ (70,351)
276 Glenn Red Bluff Joint Union HSD 11/12-3 Err:520 $ 104,658 $ 41,863 $ 62,795 $ - ### $ -
277 Glenn Red Bluff Joint Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 140,020 $ 56,008 $ (84,012)
278 Glenn Red Bluff Joint Union HSD 10/11-4 2013-Q3 $ - $ - ### $ 117,554 $ 47,022 $ (70,532)
279 Glenn Red Bluff Joint Union HSD 11/12-4 Err:520 $ 119,007 $ 47,603 $ 71,404 $ - ### $ -
280 Glenn Red Bluff Joint Union HSD 12/13-1 Err:520 $ 25,686 $ 19,265 $ 6,421
281 Glenn Red Bluff Joint Union HSD 12/13-2 Err:520 $ 32,048 $ 24,036 $ 8,012
282 Glenn Red Bluff Joint Union HSD 12/13-4 Err:520 $ 36,559 $ 27,419 $ 9,140
283 Glenn Red Bluff Joint Union HSD 12/13-3 Err:520 $ 33,011 $ 24,758 $ 8,253
284 Red Bluff Joint Union HSD Total $ 566,892 $ 271,314 $ 295,578 $ 833,144 $ 333,258 $ (499,886) $ (228,572) 25.95%
285 Glenn Red Bluff UESD 10/11-3 Err:520 $ 77,962 $ 27,287 $ 50,675 $ - ### $ -
286 Red Bluff UESD Total* $ 77,962 $ 27,287 $ 50,675 $ - $ - $ - $ 27,287 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
287 Glenn Red Bluff Union ESD 10/11-1 2012-Q4 $ - $ - ### $ 57,181 $ 20,013 $ (37,168)
288 Glenn Red Bluff Union ESD 11/12-1 Err:520 $ 40,882 $ 28,617 $ 12,265 $ - ### $ -
289 Glenn Red Bluff Union ESD 10/11-2 Err:520 $ 80,376 $ 28,132 $ 52,244 $ - ### $ -
290 Glenn Red Bluff Union ESD 11/12-2 Err:520 $ 29,610 $ 20,727 $ 8,883 $ - ### $ -
291 Glenn Red Bluff Union ESD 11/12-3 Err:520 $ 31,766 $ 22,236 $ 9,530 $ - ### $ -
292 Glenn Red Bluff Union ESD 09/10-4 2012-Q3 $ - $ - ### $ 64,845 $ 22,696 $ (42,149)
293 Glenn Red Bluff Union ESD 10/11-4 Err:520 $ 63,396 $ 22,189 $ 41,207 $ - ### $ -
294 Red Bluff Union ESD Total* $ 246,030 $ 121,901 $ 124,129 $ 122,026 $ 42,709 $ (79,317) $ 42,584 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
295 Glenn Redding ESD 10/11-1 2012-Q4 $ - $ - ### $ 26,597 $ 18,618 $ (7,979)
296 Glenn Redding ESD 10/11-2 Err:520 $ 29,337 $ 20,536 $ 8,801 $ - ### $ -
297 Glenn Redding ESD 11/12-2 Err:520 $ 35,190 $ 24,633 $ 10,557 $ - ### $ -
298 Glenn Redding ESD 10/11-3 Err:520 $ 31,750 $ 22,225 $ 9,525 $ - ### $ -
299 Glenn Redding ESD 11/12-3 Err:520 $ 28,320 $ 19,824 $ 8,496 $ - ### $ -
300 Redding ESD Total $ 124,597 $ 87,218 $ 37,379 $ 26,597 $ 18,618 $ (7,979) $ 79,239 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
301 Glenn Scott Valley USD 09/10-2 2012-Q1 $ - $ - ### $ 28,604 $ 25,000 $ (3,604) 2
302 Glenn Scott Valley USD 12/13-1 Err:520 $ 2,584 $ 2,326 $ 258
303 Glenn Scott Valley USD 12/13-2 Err:520 $ 5,594 $ 5,035 $ 559
304 Scott Valley USD Total $ 8,178 $ 7,361 $ 817 $ 28,604 $ 25,000 $ (3,604) $ 3,757 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
305 Glenn Shasta COE 10/11-1 2012-Q4 $ - $ - ### $ 30,236 $ 25,000 $ (5,236) 2
306 Glenn Shasta COE 10/11-2 2013-Q1 $ - $ - ### $ 26,801 $ 25,000 $ (1,801) 2
307 Glenn Shasta COE 10/11-3 2013-Q2 $ - $ - ### $ 28,489 $ 25,000 $ (3,489) 2
308 Glenn Shasta COE 10/11-4 2013-Q3 $ - $ - ### $ 28,221 $ 25,000 $ (3,221) 2
309 Glenn Shasta COE 12/13-1 Err:520 $ 12,666 $ 11,399 $ 1,267
310 Glenn Shasta COE 12/13-2 Err:520 $ 9,776 $ 8,798 $ 978
311 Shasta COE Total $ 22,442 $ 20,197 $ 2,245 $ 113,747 $ 100,000 $ (13,747) $ 6,450 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
312 Glenn Shasta Secondary Home School 09/10-3 2012-Q2 $ - $ - ### $ 28,306 $ 25,000 $ (3,306) 2
313 Glenn Shasta Secondary Home School 09/10-4 2012-Q3 $ - $ - ### $ 31,970 $ 25,000 $ (6,970) 2
314 Glenn Shasta Secondary Home School 12/13-1 Err:520 $ 696 $ 626 $ 70
315 Glenn Shasta Secondary Home School 12/13-2 Err:520 $ 1,654 $ 1,489 $ 165
316 Glenn Shasta Secondary Home School 13/14-1 Err:520 $ 1,977 $ 1,779 $ 198
317 Glenn Shasta Secondary Home School 13/14-2 Err:520 $ 2,664 $ 2,398 $ 266
318 Glenn Shasta Secondary Home School 13/14-3 Err:520 $ 2,730 $ 2,457 $ 273
319 Glenn Shasta Secondary Home School 13/14-4 Err:520 $ 2,654 $ 2,389 $ 265
320 Glenn Shasta Secondary Home School 12/13-4 Err:520 $ 1,887 $ 1,698 $ 189
321 Glenn Shasta Secondary Home School 12/13-3 Err:520 $ 1,275 $ 1,148 $ 127
322 Shasta Secondary Home School Total $ 15,537.00 $ 13,984.00 $ 1,553.00 $ 60,276 $ 50,000 $ (10,276) $ 3,708 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
323 Glenn Shasta Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 60,173 $ 24,069 $ (36,104)
324 Glenn Shasta Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 97,499 $ 39,000 $ (58,499)
325 Glenn Shasta Union HSD 09/10-3 2012-Q2 $ - $ - ### $ 88,651 $ 35,460 $ (53,191)
326 Glenn Shasta Union HSD 10/11-3 Err:520 $ 44,179 $ 33,134 $ 11,045 $ - ### $ -
327 Glenn Shasta Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 89,770 $ 35,908 $ (53,862)
328 Glenn Shasta Union HSD 10/11-4 Err:520 $ 57,885 $ 23,154 $ 34,731 $ - ### $ -
329 Glenn Shasta Union HSD 12/13-1 Err:520 $ 6,946 $ 6,251 $ 695
330 Glenn Shasta Union HSD 12/13-2 Err:520 $ 7,442 $ 6,698 $ 744
331 Glenn Shasta Union HSD 12/13-3 Err:520 $ 4,168 $ 3,751 $ 417
332 Glenn Shasta Union HSD 13/14-1 Err:520 $ 1,005 $ 905 $ 100
333 Glenn Shasta Union HSD 13/14-2 Err:520 $ 4,356 $ 3,920 $ 436
334 Glenn Shasta Union HSD 13/14-3 Err:520 $ 3,658 $ 3,292 $ 366
335 Glenn Shasta Union HSD 13/14-4 Err:520 $ 1,877 $ 1,689 $ 188
336 Glenn Shasta Union HSD 12/13-4 Err:520 $ 5,758 $ 5,182 $ 576
337 Shasta Union HSD Total $ 137,274 $ 87,976 $ 49,298 $ 336,093 $ 134,437 $ (201,656) $ (113,680) 12.91%
338 Glenn Siskiyou COE 10/11-1 2012-Q4 $ - $ - ### $ 28,756 $ 25,000 $ (3,756) 2
339 Glenn Siskiyou COE 11/12-1 Err:520 $ 26,673 $ 25,000 $ 1,673 $ - ### $ - 2
340 Glenn Siskiyou COE 10/11-2 2013-Q1 $ - $ - ### $ 26,117 $ 25,000 $ (1,117) 2
341 Glenn Siskiyou COE 10/11-4 2013-Q3 $ - $ - ### $ 29,000 $ 25,000 $ (4,000) 2
342 Glenn Siskiyou COE 11/12-4 Err:520 $ 25,551 $ 25,000 $ 551 $ - ### $ - 2
343 Siskiyou COE Total $ 52,224 $ 50,000 $ 2,224 $ 83,873 $ 75,000 $ (8,873) $ 41,127 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
344 Glenn Susanville SD 10/11-2 2013-Q1 $ - $ - ### $ 28,954 $ 25,000 $ (3,954) 2
345 Glenn Susanville SD 12/13-1 Err:520 $ 3,243 $ 2,919 $ 324
346 Glenn Susanville SD 12/13-2 Err:520 $ 3,776 $ 3,398 $ 378
347 Glenn Susanville SD 12/13-3 Err:520 $ 4,526.00 $ 4,073 $ 453
348 Susanville SD Total $ 11,545.00 $ 10,390.00 $ 1,155.00 $ 28,954 $ 25,000 $ (3,954) $ 6,436 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
349 Glenn Tehama County DOE-CDE 09/10-2 2012-Q1 $ - $ - ### $ 26,061 $ 25,000 $ (1,061) 2
350 Glenn Tehama County DOE-CDE 10/11-2 2013-Q1 $ - $ - ### $ 29,044 $ 25,000 $ (4,044) 2
351 Glenn Tehama County DOE-CDE 09/10-3 2012-Q2 $ - $ - ### $ 29,392 $ 25,000 $ (4,392) 2
352 Glenn Tehama County DOE-CDE 12/13-1 Err:520 $ 6,146 $ 5,531 $ 615
353 Glenn Tehama County DOE-CDE 12/13-2 Err:520 $ 6,874 $ 6,187 $ 687
354 Tehama County DOE-CDE Total $ 13,020.00 $ 11,718.00 $ 1,302.00 $ 84,497 $ 75,000 $ (9,497) $ 2,221 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
355 Glenn Thermalito Union SD 10/11-1 2012-Q4 $ - $ - ### $ 52,095 $ 20,838 $ (31,257)
356 Glenn Thermalito Union SD 09/10-3 2012-Q2 $ 87,502
357 Glenn Thermalito Union SD 11/12-1 Err:520 $ 36,582 $ 27,437 $ 9,145 $ - ### $ -
358 Glenn Thermalito Union SD 09/10-2 2012-Q1 $ - $ - ### $ 96,943 $ 38,777 $ (58,166)
359 Glenn Thermalito Union SD 10/11-2 2013-Q1 $ - $ - ### $ 87,171 $ 34,868 $ (52,303)
360 Glenn Thermalito Union SD 11/12-2 Err:520 $ 73,495 $ 29,398 $ 44,097 $ - ### $ -
361 Glenn Thermalito Union SD 10/11-3 2013-Q2 $ - $ - ### $ 95,509 $ 38,204 $ (57,305)
362 Glenn Thermalito Union SD 11/12-3 Err:520 $ 46,830 $ 35,123 $ 11,707 $ - ### $ -
363 Glenn Thermalito Union SD 09/10-4 2012-Q3 $ - $ - ### $ 70,409 $ 28,164 $ (42,245)
364 Glenn Thermalito Union SD 10/11-4 Err:520 $ 88,751 $ 35,500 $ 53,251 $ - ### $ -
365 Glenn Thermalito Union SD 11/12-4 Err:520 $ 37,173 $ 27,880 $ 9,293 $ - ### $ -
366 Glenn Thermalito Union SD 12/13-1 Err:520 $ 14,810 $ 13,329 $ 1,481
367 Glenn Thermalito Union SD 12/13-2 Err:520 $ 14,990 $ 13,491 $ 1,499
368 Glenn Thermalito Union SD 12/13-4 Err:520 $ 13,883 $ 12,495 $ 1,388
369 Glenn Thermalito Union SD 13/14-1 Err:520 $ 7,344 $ 6,610 $ 734
370 Glenn Thermalito Union SD 13/14-2 Err:520 $ 19,946 $ 17,951 $ 1,995
371 Glenn Thermalito Union SD 13/14-3 Err:520 $ 18,030 $ 16,227 $ 1,803
372 Glenn Thermalito Union SD 12/13-3 Err:520 $ 18,278 $ 16,450 $ 1,828
373 Thermalito Union SD Total $ 477,614 $ 251,891 $ 138,221 $ 402,127 $ 160,851 $ (241,276) $ 10,615 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
374 Glenn Trinity Alps USD 10/11-1 2012-Q4 $ - $ - ### $ 25,710 $ 25,000 $ (710) 2
375 Glenn Trinity Alps USD 09/10-2 2012-Q1 $ - $ - ### $ 83,759 $ 33,504 $ (50,255)
376 Glenn Trinity Alps USD 10/11-2 2013-Q1 $ - $ - ### $ 31,933 $ 25,000 $ (6,933) 2
377 Glenn Trinity Alps USD 11/12-2 Err:520 $ 27,582 $ 25,000 $ 2,582 $ - ### $ - 2
378 Glenn Trinity Alps USD 09/10-3 2012-Q2 $ - $ - ### $ 60,802 $ 24,321 $ (36,481)
379 Glenn Trinity Alps USD 10/11-3 2013-Q2 $ - $ - ### $ 29,212 $ 25,000 $ (4,212) 2
380 Glenn Trinity Alps USD 11/12-3 Err:520 $ 26,441 $ 25,000 $ 1,441 $ - ### $ - 2
381 Glenn Trinity Alps USD 09/10-4 2012-Q3 $ - $ - ### $ 59,927 $ 23,971 $ (35,956)
382 Glenn Trinity Alps USD 10/11-4 2013-Q3 $ - $ - ### $ 32,149 $ 25,000 $ (7,149) 2
383 Glenn Trinity Alps USD 11/12-4 Err:520 $ 26,233 $ 25,000 $ 1,233 $ - ### $ - 2
384 Glenn Trinity Alps USD 12/13-1 Err:520 $ 3,196 $ 2,876 $ 320
385 Glenn Trinity Alps USD 12/13-2 Err:520 $ 5,770 $ 5,193 $ 577
386 Trinity Alps USD Total $ 89,222 $ 83,069 $ 6,153 $ 323,492 $ 181,796 $ (141,696) $ (58,627) 6.66%
387 Glenn Trinity COE 09/10-4 2012-Q3 $ - $ - ### $ 37,282 $ 27,962 $ (9,320)
388 Glenn Trinity COE 12/13-1 Err:520 $ 4,538 $ 4,084 $ 454
389 Glenn Trinity COE 12/13-2 Err:520 $ 6,510 $ 5,859 $ 651
390 Trinity COE Total $ 11,048.00 $ 9,943.00 $ 1,105.00 $ 37,282 $ 27,962 $ (9,320) $ 623 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
391 Glenn Tulelake Basin Joint USD 10/11-1 Err:520 $ 25,821 $ - ### $ -
392 Glenn Tulelake Basin Joint USD 09/10-3 2012-Q2 $ - $ - ### $ 45,753 $ 34,315 $ (11,438)
A B C D E F G H I J K L M N O P Q R S T U V W X Y

2 Total amount
Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Amount to release to 2013 and CUs in Option (insert 1 Red Bluff Joint Union University Preparatory
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit Red) or 2) Chico USD Enterprise USD Gridley USD Orland USD Oroville Union HSD Paradise USD HSD Shasta Union HSD Trinity Alps USD School
393 Glenn Tulelake Basin Joint USD 11/12-3 Err:520 $ 30,695 $ 25,000 $ 5,695 $ - ### $ - 2
394 Glenn Tulelake Basin Joint USD 09/10-4 2012-Q3 $ - $ - ### $ 57,332 $ 22,933 $ (34,399)
395 Glenn Tulelake Basin Joint USD 12/13-2 Err:520 $ 10,344 $ 9,310 $ 1,034
396 Glenn Tulelake Basin Joint USD 12/13-3 Err:520 $ 12,107 $ 10,896 $ 1,211
397 Glenn Tulelake Basin Joint USD 12/13-1 Err:520 $ 11,752 $ 10,577 $ 1,175
398 Tulelake Basin Joint USD Total $ 90,719.00 $ 55,783.00 $ 9,115.00 $ 103,085 $ 57,248 $ (45,837) $ 9,946 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
399 Glenn University Preparatory School 09/10-2 2012-Q1 $ - $ - ### $ 29,013 $ 25,000 $ (4,013) 2
400 Glenn University Preparatory School 09/10-3 2012-Q2 $ - $ - ### $ 25,740 $ 25,000 $ (740) 2
401 Glenn University Preparatory School 09/10-4 2012-Q3 $ - $ - ### $ 45,690 $ 34,268 $ (11,422)
402 Glenn University Preparatory School 12/13-1 Err:520 $ 3,123 $ 2,811 $ 312
403 Glenn University Preparatory School 12/13-2 Err:520 $ 1,489 $ 1,340 $ 149
404 Glenn University Preparatory School 12/13-3 Err:520 $ 178 $ 160 $ 18
405 Glenn University Preparatory School 12/13-4 Err:520 $ 51 $ 46 $ 5
406 University Preparatory School Total $ 4,841.00 $ 4,357.00 $ 484.00 $ 100,443 $ 84,268 $ (16,175) $ (11,818) 1.34%
407 Glenn Willows USD 10/11-1 2012-Q4 $ - $ - ### $ 35,314 $ 26,486 $ (8,828)
408 Glenn Willows USD 10/11-2 2013-Q1 $ - $ - ### $ 42,230 $ 31,673 $ (10,557)
409 Glenn Willows USD 11/12-2 Err:520 $ 34,605 $ 25,954 $ 8,651 $ - ### $ - 2
410 Glenn Willows USD 10/11-3 2013-Q2 $ - $ - ### $ 36,963 $ 27,722 $ (9,241)
411 Glenn Willows USD 11/12-3 Err:520 $ 34,255 $ 25,691 $ 8,564 $ - ### $ - 2
412 Glenn Willows USD 09/10-4 2012-Q3 $ - $ - ### $ 57,189 $ 22,876 $ (34,313)
413 Glenn Willows USD 10/11-4 Err:520 $ 35,738 $ 26,804 $ 8,934 $ - ### $ -
414 Glenn Willows USD 11/12-4 Err:520 $ 30,978 $ 25,000 $ 5,978 $ - ### $ - 2
415 Willows USD Total $ 135,576 $ 103,449 $ 32,127 $ 171,696 $ 108,757 $ (62,939) $ 40,510 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
416 Glenn Yreka Union ESD 11/12-1 Err:520 $ 26,048 $ 18,234 $ 7,814 $ - ### $ -
417 Glenn Yreka Union ESD 10/11-3 2013-Q2 $ - $ - ### $ 37,185 $ 26,030 $ (11,155)
418 Glenn Yreka Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 35,330 $ 24,731 $ (10,599)
419 Glenn Yreka Union ESD 12/13-1 Err:520 $ 6,002 $ 6,002 $ -
420 Yreka Union ESD Total $ 32,050.00 $ 24,236.00 $ 7,814.00 $ 72,515 $ 50,761 $ (21,754) $ 2,482 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
421 Grand Total Glenn LEC Err:502 Err:502 Err:502 $ 9,528,054 $ 4,696,692 $ (4,831,362) Err:502 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520 Err:520
422 The sum of Column N equals the sum of "Column K" (Net Total) minus
423 the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
424 Column A County - Reporting LEC/LGA
425 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
426 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Pro-Rata Table
427 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed Check Total $ 5,187 <-- Enter check total here
428 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment Sum of Net Green Err:520
429 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made Sum of Net Red $ (880,788)
430 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
431 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
432 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
433 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
434 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
435 The last subtotal amount is the final amount due to/from the LEC/LGA
436 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
437 Column N The sum of Column N equals the sum of "Column K" (Net Total) minus the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
438 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
439 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
440 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
441

442 Released Claiming Unit Invoice on placeholder to be paid 100%


443

444 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
445 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
446

447 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
448 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
449 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
450 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
451

452 Claiming units no longer participating (5% reduction)


453
454 12/13 claims
455 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Imperial LGA Brawley Union ESD 11/12-2 Err:520 $ 27,199 $ 25,000 $ 2,199 $ - ### $ - 2 2381
3 Imperial LGA Brawley Union ESD 11/12-3 Err:520 $ 30,882 $ 25,000 $ 5,882 $ - ### $ - 2 3184
4 Imperial LGA Brawley Union ESD 11/12-4 Err:520 $ 29,149 $ 25,000 $ 4,149 $ - ### $ - 2 3968
5 Brawley Union ESD Total $ 87,230 $ 75,000 $ 12,230 $ - $ - $ - $ 75,000
6 Imperial LGA Brawley Union HSD 11/12-1 Err:520 $ 26,755 $ 25,000 $ 1,755 $ - ### $ - 2 1618
7 Imperial LGA Brawley Union HSD 11/12-2 Err:520 $ 32,505 $ 25,000 $ 7,505 $ - ### $ - 2 2382
8 Imperial LGA Brawley Union HSD 11/12-3 Err:520 $ 25,338 $ 25,000 $ 338 $ - ### $ - 2 3185
9 Imperial LGA Brawley Union HSD 10/11-4 Err:520 $ 29,371 $ 25,000 $ 4,371 $ - ### $ - 2 1053
10 Imperial LGA Brawley Union HSD 11/12-4 Err:520 $ 27,342 $ 25,000 $ 2,342 $ - ### $ - 2 3969
11 Brawley Union HSD Total $ 141,311 $ 125,000 $ 16,311 $ - $ - $ - $ 125,000
12 Imperial LGA El Centro ESD 10/11-1 2012-Q4 $ - $ - ### $ 52,417 $ 20,967 $ (31,450)
13 Imperial LGA El Centro ESD 11/12-1 Err:520 $ 51,586 $ 20,634 $ 30,952 $ - ### $ - 1621
14 Imperial LGA El Centro ESD 10/11-2 2013-Q1 $ - $ - ### $ 52,861 $ 21,144 $ (31,717)
15 Imperial LGA El Centro ESD 11/12-2 Err:520 $ 55,781 $ 22,312 $ 33,469 $ - ### $ - 2385
16 Imperial LGA El Centro ESD 10/11-3 2013-Q2 $ - $ - ### $ 105,190 $ 42,076 $ (63,114)
17 Imperial LGA El Centro ESD 11/12-3 Err:520 $ 75,010 $ 30,004 $ 45,006 $ - ### $ - 3188
18 Imperial LGA El Centro ESD 10/11-4 Err:520 $ 74,985 $ 29,994 $ 44,991 $ - ### $ - 1055
19 Imperial LGA El Centro ESD 11/12-4 Err:520 $ 88,949 $ 35,580 $ 53,369 $ - ### $ - 3972
20 El Centro ESD Total $ 346,311 $ 138,524 $ 207,787 $ 210,468 $ 84,187 $ (126,281) $ 12,243
21 Imperial LGA Holtville USD 10/11-3 Err:520 $ 28,000 $ 25,000 $ (3,000) 2
22 Imperial LGA Holtville USD 10/11-4 Err:520 $ 26,958 $ 25,000 $ 1,958 $ - ### $ - 2 1056
23 Holtville USD Total $ 26,958 $ 25,000 $ 1,958 $ 28,000 $ 25,000 $ (3,000) $ 22,000
24 Grand Total Imperial LGA $ 601,810 $ 363,524 $ 238,286 $ 238,468 $ 109,187 $ (129,281) $ 234,243
25
26
27 Column A County - Reporting LEC/LGA
28 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
29 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
30 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
31 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
32 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
33 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
34 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
35 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
36 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
37 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
38 The last subtotal amount is the final amount due to/from the LEC/LGA
39 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
40

41 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
42 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
43 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
44

45 Released Claiming Unit Invoice on placeholder to be paid 100%


46

47 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
48 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
49

50 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
51 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
52 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
53 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
54

55 Claiming units no longer participating (5% reduction)


56
57 12/13 claims
58 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Kern LGA Sierra Sands USD 11/12-1 Err:520 $ 27,822 $ 25,000 $ 2,822 $ - ### $ - 2 1689
3 Kern LGA Sierra Sands USD 10/11-4 Err:520 $ 27,071 $ 25,000 $ 2,071 2 1101
4 Kern LGA Sierra Sands USD 10/11-2 2013-Q1 $ - $ - ### $ 28,604 $ 25,000 $ (3,604) 2
5 Kern LGA Sierra Sands USD 11/12-2 Err:520 $ 35,110 $ 26,333 $ 8,777 $ - ### $ - 2 2456
6 Kern LGA Sierra Sands USD 11/12-3 Err:520 $ 33,730 $ 25,298 $ 8,432 $ - ### $ - 2 3275
7 Sierra Sands USD Total* $ 123,733 $ 101,631 $ 22,102 $ 28,604 $ 25,000 $ (3,604) $ 98,027
8 Grand Total Kern LGA $ 123,733 $ 101,631 $ 22,102 $ 28,604 $ 25,000 $ (3,604) $ 98,027
9
10
11 Column A County - Reporting LEC/LGA
12 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
13 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
14 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
15 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
16 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
17 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
18 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
19 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
20 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
21 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
22 The last subtotal amount is the final amount due to/from the LEC/LGA
23 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
24

25 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
26 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
27 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
28

29 Released Claiming Unit Invoice on placeholder to be paid 100%


30

31 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
32 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
33

34 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
35 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
36 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
37 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
38

39 Claiming units no longer participating (5% reduction)


40
41 12/13 claims
42 13/14 claims
A B C D E F G H I J K L M N O P Q R S T U V W

1
Pro-Rata Net Negative Distribution Table
Amount to release
2 to claiming unit
Amount to be recouped from DHCS Total amount
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata settlement withheld (FFY 2013 Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent check(s) and CUs in Red) or 2) Green Dot Public Schools Hacienda La Puente USD
3 Los Angeles ABC USD 10/11-1 2012-Q4 $ - $ - ### $ 96,864 $ 38,746 $ (58,118)
4 Los Angeles ABC USD 11/12-1 Err:520 $ 77,497 $ 30,999 $ 46,498 $ - ### $ -
5 Los Angeles ABC USD 10/11-2 2013-Q1 $ - $ - ### $ 144,339 $ 57,736 $ (86,603)
6 Los Angeles ABC USD 11/12-2 Err:520 $ 117,799 $ 47,120 $ 70,679 $ - ### $ -
7 Los Angeles ABC USD 10/11-3 Err:520 $ 143,256 $ 57,302 $ 85,954 $ - ### $ -
8 Los Angeles ABC USD 11/12-3 Err:520 $ 118,208 $ 47,283 $ 70,925 $ - ### $ -
9 Los Angeles ABC USD 10/11-4 Err:520 $ 114,244 $ 45,698 $ 68,546 $ - ### $ -
10 Los Angeles ABC USD 11/12-4 Err:520 $ 117,944 $ 47,178 $ 70,766 $ - ### $ -
11 ABC USD Total $ 688,948 $ 275,580 $ 413,368 $ 241,203 $ 96,482 $ (144,721) $ 130,859 Err:520 Err:520 Err:520 Err:520 Err:520
12 Los Angeles Alhambra SD 10/11-1 2012-Q4 $ - $ - ### $ 48,624 $ 36,468 $ (12,156) 2
13 Los Angeles Alhambra SD 11/12-1 Err:520 $ 131,887 $ 52,755 $ 79,132 $ - ### $ -
14 Los Angeles Alhambra SD 10/11-2 2013-Q1 $ - $ - ### $ 133,854 $ 53,542 $ (80,312)
15 Los Angeles Alhambra SD 11/12-2 Err:520 $ 176,918 $ 70,767 $ 106,151 $ - ### $ -
16 Los Angeles Alhambra SD 10/11-3 2013-Q2 $ - $ - ### $ 245,327 $ 98,131 $ (147,196)
17 Los Angeles Alhambra SD 11/12-3 Err:520 $ 143,564 $ 57,426 $ 86,138 $ - ### $ -
18 Los Angeles Alhambra SD 10/11-4 Err:520 $ 234,296 $ 93,718 $ 140,578 $ - ### $ -
19 Los Angeles Alhambra SD 11/12-4 Err:520 $ 219,388 $ 87,755 $ 131,633 $ - ### $ -
20 Alhambra SD Total $ 906,053 $ 362,421 $ 543,632 $ 427,805 $ 188,141 $ (239,664) $ 122,757 Err:520 Err:520 Err:520 Err:520 Err:520
21 Los Angeles Alliance for College Ready Public Schools 10/11-4 Err:520 $ 58,398 $ 20,439 $ 37,959 $ - ### $ -
22 Alliance for College Ready Public Schools Total $ 58,398 $ 20,439 $ 37,959 $ - $ - $ - $ 20,439 Err:520 Err:520 Err:520 Err:520 Err:520
23 Los Angeles Antelope Valley Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 127,303 $ 50,921 $ (76,382)
24 Los Angeles Antelope Valley Union HSD 11/12-1 Err:520 $ 127,984 $ 51,194 $ 76,790 $ - ### $ -
25 Los Angeles Antelope Valley Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 149,517 $ 59,807 $ (89,710)
26 Los Angeles Antelope Valley Union HSD 11/12-2 Err:520 $ 137,319 $ 54,928 $ 82,391 $ - ### $ -
27 Los Angeles Antelope Valley Union HSD 11/12-3 Err:520 $ 164,297 $ 65,719 $ 98,578 $ - ### $ -
28 Los Angeles Antelope Valley Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 106,742 $ 42,697 $ (64,045)
29 Los Angeles Antelope Valley Union HSD 10/11-4 Err:520 $ 138,381 $ 55,352 $ 83,029 $ - ### $ -
30 Los Angeles Antelope Valley Union HSD 11/12-4 Err:520 $ 149,258 $ 59,703 $ 89,555 $ - ### $ -
31 Antelope Valley Union HSD Total $ 717,239 $ 286,896 $ 430,343 $ 383,562 $ 153,425 $ (230,137) $ 56,759 Err:520 Err:520 Err:520 Err:520 Err:520
32 Los Angeles AZUSA USD 10/11-1 2012-Q4 $ - $ - ### $ 63,671 $ 25,468 $ (38,203)
33 Los Angeles AZUSA USD 11/12-1 Err:520 $ 46,301 $ 34,726 $ 11,575 $ - ### $ - 2
34 Los Angeles AZUSA USD 10/11-2 2013-Q1 $ - $ - $ - $ 68,197 $ 27,279 $ (40,918)
35 Los Angeles AZUSA USD 11/12-2 Err:520 $ 65,881 $ 26,352 $ 39,529 $ - ### $ -
36 Los Angeles AZUSA USD 10/11-3 2013-Q2 $ - $ - $ - $ 75,018 $ 30,007 $ (45,011)
37 Los Angeles AZUSA USD 11/12-3 Err:520 $ 95,807 $ 38,323 $ 57,484 $ - ### $ -
38 Los Angeles AZUSA USD 09/10-4 2012-Q3 $ - $ - $ - $ 75,504 $ 30,202 $ (45,302)
39 Los Angeles AZUSA USD 10/11-4 Err:520 $ 83,854 $ 33,542 $ 50,312 $ - ### $ -
40 Los Angeles AZUSA USD 11/12-4 Err:520 $ 117,964 $ 47,186 $ 70,778 $ - ### $ -
41 AZUSA USD Total $ 409,807 $ 180,129 $ 229,678 $ 282,390 $ 112,956 $ (169,434) $ 10,695 Err:520 Err:520 Err:520 Err:520 Err:520
42 Los Angeles Baldwin Park USD 10/11-1 2012-Q4 $ - $ - $ - $ 113,458 $ 45,383 $ (68,075)
43 Los Angeles Baldwin Park USD 11/12-1 Err:520 $ 139,794 $ 55,918 $ 83,876 $ - ### $ -
44 Los Angeles Baldwin Park USD 10/11-2 2013-Q1 $ - $ - $ - $ 154,499 $ 61,800 $ (92,699)
45 Los Angeles Baldwin Park USD 11/12-2 Err:520 $ 168,316 $ 67,326 $ 100,990 $ - ### $ -
46 Los Angeles Baldwin Park USD 10/11-3 2013-Q2 $ - $ - $ - $ 130,487 $ 52,195 $ (78,292)
47 Los Angeles Baldwin Park USD 11/12-3 Err:520 $ 150,272 $ 60,109 $ 90,163 $ - ### $ -
48 Los Angeles Baldwin Park USD 10/11-4 2013-Q3 $ - $ - $ - $ 90,648 $ 36,259 $ (54,389)
49 Los Angeles Baldwin Park USD 12/13-1 Err:520 $ 102,430 $ 40,972 $ 61,458
50 Los Angeles Baldwin Park USD 12/13-2 Err:520 $ 89,597 $ 35,839 $ 53,758
51 Los Angeles Baldwin Park USD 11/12-4 Err:520 $ 168,998 $ 67,599 $ 101,399 $ - ### $ -
52 Baldwin Park USD Total $ 819,407 $ 327,763 $ 491,644 $ 489,092 $ 195,637 $ (293,455) $ 34,308 Err:520 Err:520 Err:520 Err:520 Err:520
53 Los Angeles Bassett USD 11/12-3 Err:520 $ 28,256 $ 25,000 $ 3,256 $ - ### $ - 2
54 Los Angeles Bassett USD 11/12-4 Err:520 $ 28,277 $ 25,000 $ 3,277 $ - ### $ - 2
55 Bassett USD Total $ 56,533 $ 50,000 $ 6,533 $ - $ - $ - $ 50,000 Err:520 Err:520 Err:520 Err:520 Err:520
56 Los Angeles Bellflower USD 10/11-1 2012-Q4 $ - $ - $ - $ 74,605 $ 29,842 $ (44,763)
57 Los Angeles Bellflower USD 11/12-1 Err:520 $ 86,813 $ 34,725 $ 52,088 $ - ### $ -
58 Los Angeles Bellflower USD 10/11-2 2013-Q1 $ - $ - $ - $ 102,435 $ 40,974 $ (61,461)
59 Los Angeles Bellflower USD 11/12-2 Err:520 $ 109,907 $ 43,963 $ 65,944 $ - ### $ -
60 Los Angeles Bellflower USD 10/11-3 2013-Q2 $ - $ - $ - $ 113,491 $ 45,396 $ (68,095)
61 Los Angeles Bellflower USD 11/12-3 Err:520 $ 115,694 $ 46,278 $ 69,416 $ - ### $ -
62 Los Angeles Bellflower USD 10/11-4 Err:520 $ 101,779 $ 40,712 $ 61,067 $ - ### $ -
63 Los Angeles Bellflower USD 11/12-4 Err:520 $ 113,163 $ 45,265 $ 67,898 $ - ### $ -
64 Bellflower USD Total $ 527,356 $ 210,943 $ 316,413 $ 290,531 $ 116,212 $ (174,319) $ 36,624 Err:520 Err:520 Err:520 Err:520 Err:520
65 Los Angeles Bonita USD 10/11-1 2012-Q4 $ - $ - ### $ 43,861 $ 32,896 $ (10,965) 2
66 Los Angeles Bonita USD 11/12-1 Err:520 $ 52,423 $ 20,969 $ 31,454 $ - ### $ -
67 Los Angeles Bonita USD 10/11-2 2013-Q1 $ - $ - $ - $ 93,179 $ 37,272 $ (55,907)
68 Los Angeles Bonita USD 11/12-2 Err:520 $ 72,847 $ 29,139 $ 43,708 $ - ### $ -
69 Los Angeles Bonita USD 10/11-3 2013-Q2 $ - $ - ### $ 48,322 $ 36,242 $ (12,080) 2
70 Los Angeles Bonita USD 11/12-3 Err:520 $ 71,670 $ 28,668 $ 43,002 $ - ### $ -
71 Los Angeles Bonita USD 11/12-4 Err:520 $ 74,299 $ 29,720 $ 44,579 $ - ### $ -
72 Los Angeles Bonita USD 10/11-4 Err:520 $ 75,081 $ 30,032 $ 45,049 $ - ### $ -
73 Bonita USD Total $ 346,320 $ 138,528 $ 207,792 $ 185,362 $ 106,410 $ (78,952) $ 59,576 Err:520 Err:520 Err:520 Err:520 Err:520
74 Los Angeles Burbank USD 11/12-4 Err:520 $ 43,868 $ 32,901 $ 10,967 $ - ### $ - 2
75 Burbank USD Total $ 43,868 $ 32,901 $ 10,967 $ - $ - $ - $ 32,901 Err:520 Err:520 Err:520 Err:520 Err:520
76 Los Angeles Castaic Union SD 11/12-3 Err:520 $ 26,439 $ 25,000 $ 1,439 $ - ### $ - 2
77 Los Angeles Castaic Union SD 11/12-4 Err:520 $ 27,399 $ 25,000 $ 2,399 $ - ### $ - 2
78 Castaic Union SD Total $ 53,838 $ 50,000 $ 3,838 $ - $ - $ - $ 50,000 Err:520 Err:520 Err:520 Err:520 Err:520
79 Los Angeles Centinela Valley Union HSD 11/12-4 Err:520 $ 41,930 $ 31,448 $ 10,482 $ - ### $ - 2
80 Centinela Valley Union HSD Total $ 41,930 $ 31,448 $ 10,482 $ - $ - $ - $ 31,448 Err:520 Err:520 Err:520 Err:520 Err:520
81 Los Angeles Cerritos Community College 10/11-2 2013-Q1 $ - $ - ### $ 27,452 $ 25,000 $ (2,452) 2
82 Los Angeles Cerritos Community College 12/13-1 Err:520 $ 11,850 $ 10,665 $ 1,185
83 Los Angeles Cerritos Community College 10/11-4 2013-Q3 $ - $ - ### $ 26,308 $ 25,000 $ (1,308) 2
84 Cerritos Community College Total $ 11,850.00 $ 10,665.00 $ 1,185.00 $ 53,760 $ 50,000 $ (3,760) $ 6,905 Err:520 Err:520 Err:520 Err:520 Err:520
85 Los Angeles Charter Oak USD 10/11-1 2012-Q4 $ - $ - ### $ 44,259 $ 33,194 $ (11,065) 2
86 Los Angeles Charter Oak USD 11/12-1 Err:520 $ 47,771 $ 35,828 $ 11,943 $ - ### $ - 2
87 Los Angeles Charter Oak USD 10/11-2 2013-Q1 $ - $ - $ - $ 62,614 $ 25,046 $ (37,568)
88 Los Angeles Charter Oak USD 11/12-2 Err:520 $ 76,702 $ 30,681 $ 46,021 $ - ### $ -
89 Los Angeles Charter Oak USD 10/11-3 2013-Q2 $ - $ - $ - $ 77,831 $ 31,132 $ (46,699)
90 Los Angeles Charter Oak USD 11/12-3 Err:520 $ 94,559 $ 37,824 $ 56,735 $ - ### $ -
91 Los Angeles Charter Oak USD 10/11-4 Err:520 $ 82,437 $ 32,975 $ 49,462 $ - ### $ -
92 Los Angeles Charter Oak USD 11/12-4 Err:520 $ 127,357 $ 50,943 $ 76,414 $ - ### $ -
93 Charter Oak USD Total $ 428,826 $ 188,251 $ 240,575 $ 184,704 $ 89,372 $ (95,332) $ 92,919 Err:520 Err:520 Err:520 Err:520 Err:520
94 Los Angeles Claremont USD 11/12-1 Err:520 $ 33,720 $ 23,604 $ 10,116 $ - ### $ -
95 Los Angeles Claremont USD 11/12-2 Err:520 $ 39,603 $ 27,722 $ 11,881 $ - ### $ -
96 Los Angeles Claremont USD 10/11-4 Err:520 $ 36,533 $ 25,573 $ 10,960 $ - ### $ -
97 Los Angeles Claremont USD 11/12-4 Err:520 $ 38,012 $ 26,608 $ 11,404 $ - ### $ -
98 Claremont USD Total $ 147,868 $ 103,507 $ 44,361 $ - $ - $ - $ 103,507 Err:520 Err:520 Err:520 Err:520 Err:520
99 Los Angeles Compton USD 10/11-2 2013-Q1 $ - $ - ### $ 25,141 $ 25,000 $ (141) 2
100 Los Angeles Compton USD 11/12-2 Err:520 $ 41,062 $ 30,797 $ 10,265 $ - ### $ - 2
101 Los Angeles Compton USD 11/12-3 Err:520 $ 73,464 $ 29,386 $ 44,078 $ - ### $ -
102 Los Angeles Compton USD 11/12-4 Err:520 $ 45,969 $ 34,477 $ 11,492 $ - ### $ - 2
103 Compton USD Total $ 160,495 $ 94,660 $ 65,835 $ 25,141 $ 25,000 $ (141) $ 94,519 Err:520 Err:520 Err:520 Err:520 Err:520
104 Los Angeles Covina Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 28,746 $ 25,000 $ (3,746) 2
105 Los Angeles Covina-Valley USD 10/11-4 Err:520 $ 57,766 $ 23,106 $ 34,660 $ - ### $ -
106 Los Angeles Covina Valley USD 11/12-1 Err:520 $ 67,612 $ 27,045 $ 40,567 $ - ### $ -
107 Los Angeles Covina Valley USD 10/11-2 2013-Q1 $ - $ - $ - $ 75,901 $ 30,360 $ (45,541)
108 Los Angeles Covina Valley USD 11/12-2 Err:520 $ 113,399 $ 45,360 $ 68,039 $ - ### $ -
109 Los Angeles Covina Valley USD 10/11-3 2013-Q2 $ - $ - $ - $ 75,091 $ 30,036 $ (45,055)
110 Los Angeles Covina Valley USD 11/12-3 Err:520 $ 116,607 $ 46,643 $ 69,964 $ - ### $ -
111 Los Angeles Covina Valley USD 09/10-4 2012-Q3 $ - $ - $ - $ 84,498 $ 33,799 $ (50,699)
112 Los Angeles Covina Valley USD 11/12-4 Err:520 $ 117,219 $ 46,888 $ 70,331 $ - ### $ -
113 Covina Valley USD Total $ 472,603 $ 189,042 $ 283,561 $ 264,236 $ 119,195 $ (145,041) $ 44,001 Err:520 Err:520 Err:520 Err:520 Err:520
114 Los Angeles Downey USD 10/11-1 2012-Q4 $ - $ - $ - $ 135,813 $ 54,325 $ (81,488)
115 Los Angeles Downey USD 11/12-1 Err:520 $ 243,290 $ 97,316 $ 145,974 $ - ### $ -
116 Los Angeles Downey USD 10/11-2 2013-Q1 $ - $ - $ - $ 396,146 $ 158,458 $ (237,688)
117 Los Angeles Downey USD 11/12-2 Err:520 $ 421,277 $ 168,511 $ 252,766 $ - ### $ -
118 Los Angeles Downey USD 10/11-3 2013-Q2 $ - $ - $ - $ 316,522 $ 126,609 $ (189,913)
119 Los Angeles Downey USD 11/12-3 Err:520 $ 434,042 $ 173,617 $ 260,425 $ - ### $ -
120 Los Angeles Downey USD 10/11-4 Err:520 $ 366,475 $ 146,590 $ 219,885 $ - ### $ -
121 Los Angeles Downey USD 11/12-4 Err:520 $ 445,332 $ 178,133 $ 267,199 $ - ### $ -
122 Downey USD Total $ 1,910,416 $ 764,167 $ 1,146,249 $ 848,481 $ 339,392 $ (509,089) $ 255,078 Err:520 Err:520 Err:520 Err:520 Err:520
123 Los Angeles Duarte USD 10/11-2 2013-Q1 $ - $ - $ - $ 65,298 $ 65,298 $ -
124 Los Angeles Duarte USD 10/11-3 2013-Q2 $ - $ - ### $ 49,256 $ 49,256 $ - 2
125 Los Angeles Duarte USD 09/10-4 2012-Q3 $ - $ - ### $ 37,034 $ 37,034 $ - 2
126 Los Angeles Duarte USD 11/12-4 Err:520 $ - $ - $ - ### $ - 2
127 Duarte USD Total $ - $ - $ - $ 151,588 $ 151,588 $ - $ -
128 Los Angeles East Whittier City SD 10/11-1 2012-Q4 $ - $ - $ - $ 103,172 $ 41,269 $ (61,903)
A B C D E F G H I J K L M N O P Q R S T U V W

Amount to release
2 to claiming unit
Amount to be recouped from DHCS Total amount
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata settlement withheld (FFY 2013 Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent check(s) and CUs in Red) or 2) Green Dot Public Schools Hacienda La Puente USD
129 Los Angeles East Whittier City SD 11/12-1 Err:520 $ 99,581 $ 39,832 $ 59,749 $ - ### $ -
130 Los Angeles East Whittier City SD 10/11-2 2013-Q1 $ - $ - $ - $ 169,813 $ 67,925 $ (101,888)
131 Los Angeles East Whittier City SD 11/12-2 Err:520 $ 188,666 $ 75,466 $ 113,200 $ - ### $ -
132 Los Angeles East Whittier City SD 10/11-3 2013-Q2 $ - $ - $ - $ 184,948 $ 73,979 $ (110,969)
133 Los Angeles East Whittier City SD 11/12-3 Err:520 $ 104,141 $ 41,656 $ 62,485 $ - ### $ -
134 Los Angeles East Whittier City SD 10/11-4 Err:520 $ 198,866 $ 79,546 $ 119,320 $ - ### $ -
135 Los Angeles East Whittier City SD 11/12-4 Err:520 $ 198,104 $ 79,242 $ 118,862 $ - ### $ -
136 East Whittier City SD Total $ 789,358 $ 315,742 $ 473,616 $ 457,933 $ 183,173 $ (274,760) $ 40,982 Err:520 Err:520 Err:520 Err:520 Err:520
137 Los Angeles Eastside Union ESD 10/11-1 2012-Q4 $ - $ - $ - $ 38,898 $ 27,229 $ (11,669)
138 Los Angeles Eastside Union ESD 10/11-2 2013-Q1 $ - $ - $ - $ 37,729 $ 26,410 $ (11,319)
139 Los Angeles Eastside Union ESD 11/12-2 Err:520 $ 43,201 $ 30,241 $ 12,960 $ - ### $ -
140 Los Angeles Eastside Union ESD 10/11-3 2013-Q2 $ - $ - $ - $ 43,476 $ 30,433 $ (13,043)
141 Los Angeles Eastside Union ESD 10/11-4 Err:520 $ 37,918 $ 26,543 $ 11,375 $ - ### $ -
142 Eastside Union ESD Total $ 81,119 $ 56,784 $ 24,335 $ 120,103 $ 84,072 $ (36,031) $ 20,753 Err:520 Err:520 Err:520 Err:520 Err:520
143 Los Angeles El Camino College 11/12-1 Err:520 $ 37,246 $ 26,072 $ 11,174 $ - ### $ -
144 Los Angeles El Camino College 10/11-2 2013-Q1 $ - $ - $ - $ 25,195 $ 17,637 $ (7,558)
145 Los Angeles El Camino College 11/12-2 Err:520 $ 34,092 $ 23,864 $ 10,228 $ - ### $ -
146 Los Angeles El Camino College 10/11-3 2013-Q2 $ - $ - $ - $ 25,862 $ 18,103 $ (7,759)
147 Los Angeles El Camino College 11/12-3 Err:520 $ 32,518 $ 22,763 $ 9,755 $ - ### $ -
148 Los Angeles El Camino College 11/12-4 Err:520 $ 37,673 $ 26,371 $ 11,302 $ - ### $ -
149 El Camino College Total $ 141,529 $ 99,070 $ 42,459 $ 51,057 $ 35,740 $ (15,317) $ 83,753 Err:520 Err:520 Err:520 Err:520 Err:520
150 Los Angeles El Monte City SD 10/11-1 2012-Q4 $ - $ - $ - $ 152,127 $ 60,851 $ (91,276)
151 Los Angeles El Monte City SD 11/12-1 Err:520 $ 160,978 $ 64,391 $ 96,587 $ - ### $ -
152 Los Angeles El Monte City SD 10/11-2 2013-Q1 $ - $ - $ - $ 275,537 $ 110,215 $ (165,322)
153 Los Angeles El Monte City SD 11/12-2 Err:520 $ 296,824 $ 118,730 $ 178,094 $ - ### $ -
154 Los Angeles El Monte City SD 10/11-3 2013-Q2 $ - $ - $ - $ 237,362 $ 94,945 $ (142,417)
155 Los Angeles El Monte City SD 11/12-3 Err:520 $ 301,464 $ 120,586 $ 180,878 $ - ### $ -
156 Los Angeles El Monte City SD 10/11-4 Err:520 $ 260,596 $ 104,238 $ 156,358 $ - ### $ -
157 Los Angeles El Monte City SD 11/12-4 Err:520 $ 288,726 $ 115,490 $ 173,236 $ - ### $ -
158 El Monte City SD Total $ 1,308,588 $ 523,435 $ 785,153 $ 665,026 $ 266,011 $ (399,015) $ 124,420 Err:520 Err:520 Err:520 Err:520 Err:520
159 Los Angeles El Monte Union HSD 10/11-2 2013-Q1 $ - $ - $ - $ 73,840 $ 29,536 $ (44,304)
160 Los Angeles El Monte Union HSD 11/12-2 Err:520 $ 27,216 $ 25,000 $ 2,216 $ - ### $ - 2
161 Los Angeles El Monte Union HSD 10/11-3 2013-Q2 $ - $ - $ - $ 112,766 $ 45,106 $ (67,660)
162 Los Angeles El Monte Union HSD 12/13-1 Err:520 $ 6,479 $ 5,831 $ 648
163 Los Angeles El Monte Union HSD 12/13-2 Err:520 $ 12,740 $ 11,466 $ 1,274
164 Los Angeles El Monte Union HSD 12/13-3 Err:520 $ 7,640 $ 6,876 $ 764
165 Los Angeles El Monte Union HSD 12/13-4 Err:520 $ 5,537 $ 4,983 $ 554
166 Los Angeles El Monte Union HSD 13/14-1 Err:520 $ 8,555 $ 7,700 $ 855
167 Los Angeles El Monte Union HSD 13/14-2 Err:520 $ 23,907 $ 21,516 $ 2,391
168 Los Angeles El Monte Union HSD 13/14-3 Err:520 $ 17,997 $ 16,197 $ 1,800
169 Los Angeles El Monte Union HSD 10/11-4 Err:520 $ 59,191 $ 23,676 $ 35,515 $ - ### $ -
170 El Monte Union HSD Total $ 169,262 $ 123,245 $ 46,017 $ 186,606 $ 74,642 $ (111,964) $ 11,281 Err:520 Err:520 Err:520 Err:520 Err:520
171 Los Angeles El Rancho USD 10/11-1 2012-Q4 $ - $ - $ - $ 148,874 $ 59,550 $ (89,324)
172 Los Angeles El Rancho USD 10/11-2 2013-Q1 $ - $ - $ - $ 256,744 $ 102,698 $ (154,046)
173 Los Angeles El Rancho USD 11/12-2 Err:520 $ 411,857 $ 164,743 $ 247,114 $ - ### $ -
174 Los Angeles El Rancho USD 10/11-3 2013-Q2 $ - $ - $ - $ 279,872 $ 111,949 $ (167,923)
175 Los Angeles El Rancho USD 11/12-3 Err:520 $ 325,480 $ 130,192 $ 195,288 $ - ### $ -
176 Los Angeles El Rancho USD 10/11-4 Err:520 $ 298,374 $ 119,350 $ 179,024 $ - ### $ -
177 Los Angeles El Rancho USD 11/12-4 Err:520 $ 188,296 $ 75,318 $ 112,978 $ - ### $ -
178 Los Angeles El Rancho USD 11/12-1C-1 Err:520 $ 207,895 $ 83,158 $ 124,737 $ - ### $ -
179 El Rancho USD Total $ 1,431,902 $ 572,761 $ 859,141 $ 685,490 $ 274,197 $ (411,293) $ 161,468 Err:520 Err:520 Err:520 Err:520 Err:520
180 Los Angeles Glendale USD 10/11-1 2012-Q4 $ - $ - $ - $ 185,033 $ 185,033 $ -
181 Los Angeles Glendale USD 10/11-2 2013-Q1 $ - $ - $ - $ 279,431 $ 279,431 $ -
182 Los Angeles Glendale USD 10/11-3 2013-Q2 $ - $ - $ - $ 260,132 $ 260,132 $ -
183 Los Angeles Glendale USD 09/10-4 2012-Q3 $ - $ - $ - $ 151,534 $ 151,534 $ -
184 Los Angeles Glendale USD 11/12-4 Err:520 $ 307,463 $ 307,463 $ - $ - ### $ -
185 Los Angeles Glendale USD 11/12-3C-1 Err:520 $ 268,338 $ 268,338 $ - $ - ### $ -
186 Glendale USD Total $ 575,801 $ 575,801 $ - $ 876,130 $ 876,130 $ - $ 575,801 Err:520 Err:520 Err:520 Err:520 Err:520
187 Los Angeles Glendora USD 11/12-2 Err:520 $ 30,587 $ 25,000 $ 5,587 $ - ### $ - 2
188 Los Angeles Glendora USD 11/12-3 Err:520 $ 26,018 $ 25,000 $ 1,018 $ - ### $ - 2
189 Los Angeles Glendora USD 10/11-4 Err:520 $ 30,185 $ 25,000 $ 5,185 $ - ### $ - 2
190 Los Angeles Glendora USD 11/12-4 Err:520 $ 25,364 $ 25,000 $ 364 $ - ### $ - 2
191 Glendora USD Total $ 112,154 $ 100,000 $ 12,154 $ - $ - $ - $ 100,000 Err:520 Err:520 Err:520 Err:520 Err:520
192 Los Angeles Green Dot Public Schools 10/11-1 2012-Q4 $ - $ - $ - $ 144,840 $ 50,694 $ (94,146)
193 Los Angeles Green Dot Public Schools 11/12-1 Err:520 $ 221,212 $ - ### $ -
194 Los Angeles Green Dot Public Schools 10/11-2 2013-Q1 $ - $ - $ - $ 73,655 $ 25,779 $ (47,876)
195 Los Angeles Green Dot Public Schools 11/12-2 Err:520 $ 148,659 $ - ### $ -
196 Los Angeles Green Dot Public Schools 10/11-3 2013-Q2 $ - $ - $ - $ 87,031 $ 30,461 $ (56,570)
197 Los Angeles Green Dot Public Schools 11/12-3 Err:520 $ 113,340 $ - ### $ -
198 Los Angeles Green Dot Public Schools 09/10-4 2012-Q3 $ - $ - $ - $ 146,731 $ 51,356 $ (95,375)
199 Los Angeles Green Dot Public Schools 12/13-1 Err:520 $ 22,919
200 Los Angeles Green Dot Public Schools 12/13-2 Err:520 $ 21,194
201 Los Angeles Green Dot Public Schools 12/13-3 Err:520 $ 17,603
202 Los Angeles Green Dot Public Schools 12/13-4 Err:520 $ 9,779
203 Los Angeles Green Dot Public Schools 10/11-4 Err:520 $ 88,705 $ - ### $ -
204 Los Angeles Green Dot Public Schools 11/12-4 Err:520 $ 59,728 $ - ### $ -
205 Green Dot Public Schools Total $ 703,139 $ - $ - $ 452,257 $ 158,290 $ (293,967) $ (293,967) 81.32%
206 Los Angeles Hacienda La Puente USD 11/12-2 Err:520 $ 63,490 $ 22,222 $ 41,268 $ - ### $ -
207 Los Angeles Hacienda La Puente USD 10/11-3 2013-Q2 $ - $ - $ - $ 177,889 $ 62,261 $ (115,628)
208 Los Angeles Hacienda La Puente USD 11/12-3 Err:520 $ 46,264 $ 32,385 $ 13,879 $ - ### $ -
209 Los Angeles Hacienda La Puente USD 10/11-4 2013-Q3 $ - $ - $ - $ 103,428 $ 36,200 $ (67,228)
210 Los Angeles Hacienda La Puente USD 12/13-1 Err:520 $ 11,095 $ 11,095 $ -
211 Los Angeles Hacienda La Puente USD 12/13-2 Err:520 $ 7,915 $ 7,915 $ -
212 Los Angeles Hacienda La Puente USD 12/13-3 Err:520 $ 9,827 $ 9,827 $ -
213 Los Angeles Hacienda La Puente USD 12/13-4 Err:520 $ 4,753 $ 4,753 $ -
214 Los Angeles Hacienda La Puente USD 11/12-4 Err:520 $ 38,760 $ 27,132 $ 11,628 $ - ### $ -
215 Hacienda La Puente USD Total $ 182,104 $ 115,329 $ 66,775 $ 281,317 $ 98,461 $ (182,856) $ (67,527) 18.68%
216 Los Angeles Hawthorne SD 10/11-1 2012-Q4 $ - $ - $ - $ 33,393 $ 23,375 $ (10,018)
217 Los Angeles Hawthorne SD 11/12-1 Err:520 $ 52,025 $ 18,209 $ 33,816 $ - ### $ -
218 Los Angeles Hawthorne SD 10/11-2 2013-Q1 $ - $ - $ - $ 33,083 $ 23,158 $ (9,925)
219 Los Angeles Hawthorne SD 11/12-2 Err:520 $ 56,944 $ 19,930 $ 37,014 $ - ### $ -
220 Los Angeles Hawthorne SD 10/11-3 2013-Q2 $ - $ - $ - $ 36,931 $ 25,852 $ (11,079)
221 Los Angeles Hawthorne SD 11/12-3 Err:520 $ 39,180 $ 27,426 $ 11,754 $ - ### $ -
222 Los Angeles Hawthorne SD 10/11-4 Err:520 $ 41,343 $ 28,940 $ 12,403 $ - ### $ -
223 Los Angeles Hawthorne SD 11/12-4 Err:520 $ 67,821 $ 23,737 $ 44,084 $ - ### $ -
224 Hawthorne SD Total $ 257,313 $ 118,242 $ 139,071 $ 103,407 $ 72,385 $ (31,022) $ 87,220 Err:520 Err:520 Err:520 Err:520 Err:520
225 Los Angeles Inglewood USD 10/11-2 2013-Q1 $ - $ - ### $ 31,871 $ 25,000 $ (6,871) 2
226 Los Angeles Inglewood USD 10/11-3 2013-Q2 $ - $ - ### $ 25,516 $ 25,000 $ (516) 2
227 Los Angeles Inglewood USD 11/12-3 Err:520 $ 53,067 $ 21,227 $ 31,840 $ - ### $ -
228 Los Angeles Inglewood USD 11/12-4 Err:520 $ 52,331 $ 20,932 $ 31,399 $ - ### $ -
229 Inglewood USD Total $ 105,398 $ 42,159 $ 63,239 $ 57,387 $ 50,000 $ (7,387) $ 34,772 Err:520 Err:520 Err:520 Err:520 Err:520
230 Los Angeles Lancaster SD 10/11-1 2012-Q4 $ - $ - $ - $ 65,673 $ 26,269 $ (39,404)
231 Los Angeles Lancaster SD 11/12-1 Err:520 $ 74,602 $ 29,841 $ 44,761 $ - ### $ -
232 Los Angeles Lancaster SD 10/11-2 2013-Q1 $ - $ - $ - $ 71,177 $ 28,471 $ (42,706)
233 Los Angeles Lancaster SD 11/12-2 Err:520 $ 75,856 $ 30,342 $ 45,514 $ - ### $ -
234 Los Angeles Lancaster SD 10/11-3 2013-Q2 $ - $ - $ - $ 71,822 $ 28,729 $ (43,093)
235 Los Angeles Lancaster SD 11/12-3 Err:520 $ 61,623 $ 24,649 $ 36,974 $ - ### $ -
236 Los Angeles Lancaster SD 10/11-4 Err:520 $ 75,457 $ 30,183 $ 45,274 $ - ### $ -
237 Los Angeles Lancaster SD 11/12-4 Err:520 $ 101,280 $ 40,512 $ 60,768 $ - ### $ -
238 Lancaster SD Total $ 388,818 $ 155,527 $ 233,291 $ 208,672 $ 83,469 $ (125,203) $ 30,324 Err:520 Err:520 Err:520 Err:520 Err:520
239 Los Angeles Las Virgenes USD 10/11-2 2013-Q1 $ - $ - $ - $ 42,997 $ 30,098 $ (12,899)
240 Los Angeles Las Virgenes USD 11/12-2 Err:520 $ 37,133 $ 25,993 $ 11,140 $ - ### $ -
241 Los Angeles Las Virgenes USD 10/11-3 2013-Q2 $ - $ - $ - $ 49,559 $ 34,691 $ (14,868)
242 Los Angeles Las Virgenes USD 11/12-3 Err:520 $ 36,721 $ 25,705 $ 11,016 $ - ### $ -
243 Los Angeles Las Virgenes USD 10/11-4 Err:520 $ 49,851 $ 34,896 $ 14,955 $ - ### $ -
244 Los Angeles Las Virgenes USD 11/12-4 Err:520 $ 35,169 $ 24,618 $ 10,551 $ - ### $ -
245 Las Virgenes USD Total $ 158,874 $ 111,212 $ 47,662 $ 92,556 $ 64,789 $ (27,767) $ 83,445 Err:520 Err:520 Err:520 Err:520 Err:520
246 Los Angeles Lawndale ESD - PPS 10/11-1 2012-Q4 $ - $ - ### $ 37,726 $ 28,295 $ (9,431) 2
247 Los Angeles Lawndale ESD - PPS 11/12-1 Err:520 $ 41,587 $ 31,190 $ 10,397 $ - ### $ - 2
248 Los Angeles Lawndale ESD - PPS 10/11-2 2013-Q1 $ - $ - $ - $ 69,887 $ 27,955 $ (41,932)
249 Los Angeles Lawndale ESD - PPS 11/12-2 Err:520 $ 101,572 $ 40,629 $ 60,943 $ - ### $ -
250 Los Angeles Lawndale ESD - PPS 10/11-3 2013-Q2 $ - $ - $ - $ 80,150 $ 32,060 $ (48,090)
251 Los Angeles Lawndale ESD - PPS 11/12-3 Err:520 $ 88,863 $ 35,545 $ 53,318 $ - ### $ -
252 Los Angeles Lawndale ESD - PPS 10/11-4 2013-Q3 $ - $ - $ - $ 92,045 $ 36,818 $ (55,227)
253 Los Angeles Lawndale ESD - PPS 11/12-4 Err:520 $ 118,384 $ 47,354 $ 71,030 $ - ### $ -
254 Lawndale ESD - PPS Total $ 350,406 $ 154,718 $ 195,688 $ 279,808 $ 125,128 $ (154,680) $ 38 Err:520 Err:520 Err:520 Err:520 Err:520
255 Los Angeles Lennox SD-Pupil Health Services 10/11-1 2012-Q4 $ - $ - ### $ 46,963 $ 46,963 $ -
256 Los Angeles Lennox SD-Pupil Health Services 10/11-2 2013-Q1 $ - $ - ### $ 25,845 $ 25,845 $ -
A B C D E F G H I J K L M N O P Q R S T U V W

Amount to release
2 to claiming unit
Amount to be recouped from DHCS Total amount
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata settlement withheld (FFY 2013 Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent check(s) and CUs in Red) or 2) Green Dot Public Schools Hacienda La Puente USD
257 Los Angeles Lennox SD-Pupil Health Services 10/11-3 2013-Q2 $ - $ - ### $ 29,910 $ 29,910 $ -
258 Los Angeles Lennox SD-Pupil Health Services 11/12-4 Err:520 $ - $ - $ - ### $ -
259 Lennox SD-Pupil Health Services Total $ - $ - $ - $ 102,718 $ 102,718 $ - $ -
260 Los Angeles Little Lake City ESD 10/11-2 2013-Q1 $ - $ - ### $ 41,703 $ 31,277 $ (10,426) 2
261 Los Angeles Little Lake City ESD 11/12-4 Err:520 $ 27,914 $ 25,000 $ 2,914 $ - ### $ - 2
262 Little Lake City ESD Total $ 27,914 $ 25,000 $ 2,914 $ 41,703 $ 31,277 $ (10,426) $ 14,574 Err:520 Err:520 Err:520 Err:520 Err:520
263 Los Angeles Long Beach USD 11/12-2 Err:520 $ 293,513 $ 117,405 $ 176,108 $ - ### $ -
264 Los Angeles Long Beach USD 11/12-3 Err:520 $ 228,611 $ 91,444 $ 137,167 $ - ### $ -
265 Los Angeles Long Beach USD 10/11-1 2012-Q4 $ - $ - $ - $ 229,161 $ 91,664 $ (137,497)
266 Los Angeles Long Beach USD 11/12-1 Err:520 $ 175,176 $ 70,070 $ 105,106 $ - ### $ -
267 Los Angeles Long Beach USD 10/11-2 2013-Q1 $ - $ - $ - $ 269,309 $ 107,724 $ (161,585)
268 Los Angeles Long Beach USD 10/11-3 2013-Q2 $ - $ - $ - $ 276,287 $ 110,515 $ (165,772)
269 Los Angeles Long Beach USD 10/11-4 Err:520 $ 257,920 $ 103,168 $ 154,752 $ - ### $ -
270 Los Angeles Long Beach USD 11/12-4 Err:520 $ 233,574 $ 93,430 $ 140,144 $ - ### $ -
271 Long Beach USD Total $ 1,188,794 $ 475,517 $ 713,277 $ 774,757 $ 309,903 $ (464,854) $ 10,663 Err:520 Err:520 Err:520 Err:520 Err:520
272 Los Angeles Los Angeles COE 10/11-1 2012-Q4 $ - $ - $ - $ 463,181 $ 185,272 $ (277,909)
273 Los Angeles Los Angeles COE 11/12-1 Err:520 $ 485,407 $ 194,163 $ 291,244 $ - ### $ -
274 Los Angeles Los Angeles COE 10/11-2 2013-Q1 $ - $ - $ - $ 605,758 $ 242,303 $ (363,455)
275 Los Angeles Los Angeles COE 11/12-2 Err:520 $ 689,937 $ 275,975 $ 413,962 $ - ### $ -
276 Los Angeles Los Angeles COE 10/11-3 Err:520 $ 667,379 $ 266,952 $ 400,427 $ - ### $ -
277 Los Angeles Los Angeles COE 11/12-3 Err:520 $ 526,722 $ 210,689 $ 316,033 $ - ### $ -
278 Los Angeles Los Angeles COE 09/10-4 2012-Q3 $ - $ - $ - $ 760,280 $ 304,112 $ (456,168)
279 Los Angeles Los Angeles COE 10/11-4 Err:520 $ 734,539 $ 293,816 $ 440,723 $ - ### $ -
280 Los Angeles Los Angeles COE 11/12-4 Err:520 $ 648,307 $ 259,323 $ 388,984 $ - ### $ -
281 Los Angeles COE Total $ 3,752,291 $ 1,500,918 $ 2,251,373 $ 1,829,219 $ 731,687 $ (1,097,532) $ 403,386 Err:520 Err:520 Err:520 Err:520 Err:520
282 Los Angeles Lynwood USD 10/11-1 2012-Q4 $ - $ - $ - $ 98,885 $ 98,885 $ -
283 Los Angeles Lynwood USD 10/11-2 2013-Q1 $ - $ - ### $ 40,541 $ 40,541 $ - 2
284 Los Angeles Lynwood USD 10/11-3 2013-Q2 $ - $ - ### $ 33,209 $ 33,209 $ - 2
285 Los Angeles Lynwood USD 09/10-4 2012-Q3 $ - $ - $ - $ 256,176 $ 256,176 $ -
286 Los Angeles Lynwood USD 11/12-4 Err:520 $ - $ - $ - ### $ -
287 Lynwood USD Total $ - $ - $ - $ 428,811 $ 428,811 $ - $ -
288 Los Angeles Monrovia USD 10/11-1 2012-Q4 $ - $ - $ - $ 81,820 $ 32,728 $ (49,092)
289 Los Angeles Monrovia USD 11/12-1 Err:520 $ 68,871 $ 27,548 $ 41,323 $ - ### $ -
290 Los Angeles Monrovia USD 10/11-2 2013-Q1 $ - $ - $ - $ 90,941 $ 36,376 $ (54,565)
291 Los Angeles Monrovia USD 11/12-2 Err:520 $ 80,028 $ 32,011 $ 48,017 $ - ### $ -
292 Los Angeles Monrovia USD 10/11-3 Err:520 $ 102,137 $ 40,855 $ 61,282 $ - ### $ -
293 Los Angeles Monrovia USD 11/12-3 Err:520 $ 84,453 $ 33,781 $ 50,672 $ - ### $ -
294 Los Angeles Monrovia USD 09/10-4 2012-Q3 $ - $ - $ - $ 116,002 $ 46,401 $ (69,601)
295 Los Angeles Monrovia USD 10/11-4 Err:520 $ 93,555 $ 37,422 $ 56,133 $ - ### $ -
296 Los Angeles Monrovia USD 11/12-4 Err:520 $ 77,381 $ 30,952 $ 46,429 $ - ### $ -
297 Monrovia USD Total $ 506,425 $ 202,569 $ 303,856 $ 288,763 $ 115,505 $ (173,258) $ 29,311 Err:520 Err:520 Err:520 Err:520 Err:520
298 Los Angeles Montebello USD 10/11-1 2012-Q4 $ - $ - $ - $ 163,650 $ 65,460 $ (98,190)
299 Los Angeles Montebello USD 10/11-2 2013-Q1 $ - $ - $ - $ 173,661 $ 69,464 $ (104,197)
300 Los Angeles Montebello USD 11/12-2 Err:520 $ 278,635 $ 111,454 $ 167,181 $ - ### $ -
301 Los Angeles Montebello USD 10/11-3 Err:520 $ 194,212 $ 77,685 $ 116,527 $ - ### $ -
302 Los Angeles Montebello USD 11/12-3 Err:520 $ 279,573 $ 111,829 $ 167,744 $ - ### $ -
303 Los Angeles Montebello USD 10/11-4 Err:520 $ 207,440 $ 82,976 $ 124,464 $ - ### $ -
304 Los Angeles Montebello USD 11/12-4 Err:520 $ 252,966 $ 101,186 $ 151,780 $ - ### $ -
305 Los Angeles Montebello USD 11/12-1C-1 Err:520 $ 201,946 $ 80,778 $ 121,168 $ - ### $ -
306 Montebello USD Total $ 1,414,772 $ 565,908 $ 848,864 $ 337,311 $ 134,924 $ (202,387) $ 363,521 Err:520 Err:520 Err:520 Err:520 Err:520
307 Los Angeles Mountain View SD 11/12-3 Err:520 $ 59,460 $ 23,784 $ 35,676 $ - ### $ -
308 Los Angeles Mountain View SD 11/12-4 Err:520 $ 37,285 $ 27,964 $ 9,321 $ - ### $ - 2
309 Mountain View SD Total $ 96,745 $ 51,748 $ 44,997 $ - $ - $ - $ 51,748 Err:520 Err:520 Err:520 Err:520 Err:520
310 Los Angeles Mt. San Antonio Comm College 11/12-1-C1 Err:520 $ 36,706 $ 25,694 $ 11,012 $ - ### $ -
311 Los Angeles Mt. San Antonio Comm College 11/12-2C-1 Err:520 $ 67,156 $ 23,505 $ 43,651 $ - ### $ -
312 Los Angeles Mt. San Antonio Comm College 11/12-3C-1 Err:520 $ 37,885 $ 26,520 $ 11,365 $ - ### $ -
313 Los Angeles Mt. San Antonio Comm College 11/12-4C-1 Err:520 $ 48,258 $ 33,781 $ 14,477 $ - ### $ -
314 Mt. San Antonio Comm College Total $ 190,005 $ 109,500 $ 80,505 $ - $ - $ - $ 109,500 Err:520 Err:520 Err:520 Err:520 Err:520
315 Los Angeles Newhall ESD 11/12-1 Err:520 $ 31,550 $ 25,000 $ 6,550 $ - ### $ - 2
316 Los Angeles Newhall ESD 10/11-2 2013-Q1 $ - $ - ### $ 35,313 $ 26,485 $ (8,828) 2
317 Los Angeles Newhall ESD 11/12-2 Err:520 $ 30,504 $ 25,000 $ 5,504 $ - ### $ - 2
318 Los Angeles Newhall ESD 10/11-3 2013-Q2 $ - $ - ### $ 29,082 $ 25,000 $ (4,082) 2
319 Los Angeles Newhall ESD 10/11-4 2013-Q3 $ - $ - ### $ 26,931 $ 25,000 $ (1,931) 2
320 Los Angeles Newhall ESD 11/12-4 Err:520 $ 42,481 $ 31,861 $ 10,620 $ - ### $ - 2
321 Newhall ESD Total $ 104,535 $ 81,861 $ 22,674 $ 91,326 $ 76,485 $ (14,841) $ 67,020 Err:520 Err:520 Err:520 Err:520 Err:520
322 Los Angeles Norwalk-La Mirada USD 10/11-1 2012-Q4 $ - $ - ### $ 34,293 $ 25,720 $ (8,573) 2
323 Los Angeles Norwalk-La Mirada USD 11/12-1 Err:520 $ 28,292 $ 25,000 $ 3,292 $ - ### $ - 2
324 Los Angeles Norwalk-La Mirada USD 10/11-2 2013-Q1 $ - $ - $ - $ 57,172 $ 22,869 $ (34,303)
325 Los Angeles Norwalk-La Mirada USD 11/12-2 Err:520 $ 50,421 $ 20,168 $ 30,253 $ - ### $ -
326 Los Angeles Norwalk-La Mirada USD 10/11-3 2013-Q2 $ - $ - ### $ 45,963 $ 34,472 $ (11,491) 2
327 Los Angeles Norwalk-La Mirada USD 11/12-3 Err:520 $ 36,578 $ 27,434 $ 9,144 $ - ### $ - 2
328 Los Angeles Norwalk-La Mirada USD 10/11-4 Err:520 $ 55,641 $ 22,256 $ 33,385 $ - ### $ -
329 Los Angeles Norwalk-La Mirada USD 11/12-4 Err:520 $ 41,403 $ 31,052 $ 10,351 $ - ### $ - 2
330 Norwalk-La Mirada USD Total $ 212,335 $ 125,910 $ 86,425 $ 137,428 $ 83,061 $ (54,367) $ 71,543 Err:520 Err:520 Err:520 Err:520 Err:520
331 Los Angeles Palmdale ESD 10/11-1 2012-Q4 $ - $ - $ - $ 164,454 $ 65,782 $ (98,672)
332 Los Angeles Palmdale ESD 11/12-1 Err:520 $ 155,622 $ 62,249 $ 93,373 $ - ### $ -
333 Los Angeles Palmdale ESD 10/11-2 2013-Q1 $ - $ - $ - $ 170,429 $ 68,172 $ (102,257)
334 Los Angeles Palmdale ESD 11/12-2 Err:520 $ 148,217 $ 59,287 $ 88,930 $ - ### $ -
335 Los Angeles Palmdale ESD 10/11-3 2013-Q2 $ - $ - $ - $ 131,379 $ 52,552 $ (78,827)
336 Los Angeles Palmdale ESD 11/12-3 Err:520 $ 170,386 $ 68,154 $ 102,232 $ - ### $ -
337 Los Angeles Palmdale ESD 09/10-4 2012-Q3 $ - $ - $ - $ 124,457 $ 49,783 $ (74,674)
338 Los Angeles Palmdale ESD 10/11-4 Err:520 $ 138,921 $ 55,568 $ 83,353 $ - ### $ -
339 Los Angeles Palmdale ESD 12/13-1 Err:520 $ 73,343 $ 29,337 $ 44,006
340 Los Angeles Palmdale ESD 12/13-2 Err:520 $ 122,774 $ 49,110 $ 73,664
341 Los Angeles Palmdale ESD 11/12-4 Err:520 $ 157,432 $ 62,973 $ 94,459 $ - ### $ -
342 Palmdale ESD Total $ 966,695 $ 386,678 $ 580,017 $ 590,719 $ 236,289 $ (354,430) $ 32,248 Err:520 Err:520 Err:520 Err:520 Err:520
343 Los Angeles Paramount USD 11/12-2 Err:520 $ 40,133 $ 30,100 $ 10,033 $ - ### $ - 2
344 Los Angeles Paramount USD 11/12-3 Err:520 $ 33,877 $ 25,408 $ 8,469 $ - ### $ - 2
345 Los Angeles Paramount USD 11/12-4 Err:520 $ 35,911 $ 26,933 $ 8,978 $ - ### $ - 2
346 Paramount USD Total $ 109,921 $ 82,441 $ 27,480 $ - $ - $ - $ 82,441 Err:520 Err:520 Err:520 Err:520 Err:520
347 Los Angeles Pomona USD 10/11-1 2012-Q4 $ - $ - $ - $ 191,903 $ 76,761 $ (115,142)
348 Los Angeles Pomona USD 11/12-1 Err:520 $ 388,087 $ 155,235 $ 232,852 $ - ### $ -
349 Los Angeles Pomona USD 10/11-2 2013-Q1 $ - $ - $ - $ 308,660 $ 123,464 $ (185,196)
350 Los Angeles Pomona USD 11/12-2 Err:520 $ 496,220 $ 198,488 $ 297,732 $ - ### $ -
351 Los Angeles Pomona USD 10/11-3 2013-Q2 $ - $ - $ - $ 304,611 $ 121,844 $ (182,767)
352 Los Angeles Pomona USD 11/12-3 Err:520 $ 463,503 $ 185,401 $ 278,102 $ - ### $ -
353 Los Angeles Pomona USD 10/11-4 Err:520 $ 291,190 $ 116,476 $ 174,714 $ - ### $ -
354 Los Angeles Pomona USD 11/12-4 Err:520 $ 513,334 $ 205,334 $ 308,000 $ - ### $ -
355 Pomona USD Total $ 2,152,334 $ 860,934 $ 1,291,400 $ 805,174 $ 322,069 $ (483,105) $ 377,829 Err:520 Err:520 Err:520 Err:520 Err:520
356 Los Angeles Redondo Beach USD 10/11-2 2013-Q1 $ - ### $ 37,580 $ 26,306 $ (11,274)
357 Los Angeles Redondo Beach USD 11/12-2 Err:520 $ 40,808 $ 28,566 $ 12,242 $ - ### $ -
358 Los Angeles Redondo Beach USD 10/11-3 2013-Q2 $ - ### $ 25,833 $ 18,083 $ (7,750)
359 Los Angeles Redondo Beach USD 10/11-4 Err:520 $ 29,358 $ 20,551 $ 8,807 $ - ### $ -
360 Los Angeles Redondo Beach USD 11/12-4 Err:520 $ 32,227 $ 22,559 $ 9,668 $ - ### $ -
361 Redondo Beach USD Total $ 102,393 $ 71,676 $ 30,717 $ 63,413 $ 44,389 $ (19,024) $ 52,652 Err:520 Err:520 Err:520 Err:520 Err:520
362 Los Angeles Rosemead SD 10/11-3 2013-Q2 $ - $ - ### $ 26,753 $ 25,000 $ (1,753) 2
363 Los Angeles Rosemead SD 10/11-4 Err:520 $ 27,397 $ 25,000 $ 2,397 $ - ### $ - 2
364 Rosemead SD Total $ 27,397 $ 25,000 $ 2,397 $ 26,753 $ 25,000 $ (1,753) $ 23,247 Err:520 Err:520 Err:520 Err:520 Err:520
365 Los Angeles Rowland USD 10/11-1 2012-Q4 $ - $ - $ - $ 192,565 $ 77,026 $ (115,539)
366 Los Angeles Rowland USD 11/12-1 Err:520 $ 155,120 $ 62,048 $ 93,072 $ - ### $ -
367 Los Angeles Rowland USD 10/11-2 2013-Q1 $ - $ - $ - $ 350,740 $ 140,296 $ (210,444)
368 Los Angeles Rowland USD 11/12-2 Err:520 $ 263,713 $ 105,485 $ 158,228 $ - ### $ -
369 Los Angeles Rowland USD 10/11-3 2013-Q2 $ - $ - $ - $ 370,272 $ 148,109 $ (222,163)
370 Los Angeles Rowland USD 11/12-3 Err:520 $ 284,136 $ 113,654 $ 170,482 $ - ### $ -
371 Los Angeles Rowland USD 09/10-4 2012-Q3 $ - $ - $ - $ 344,823 $ 137,929 $ (206,894)
372 Los Angeles Rowland USD 10/11-4 Err:520 $ 375,629 $ 150,252 $ 225,377 $ - ### $ -
373 Los Angeles Rowland USD 12/13-1 Err:520 $ 135,548 $ 54,219 $ 81,329
374 Los Angeles Rowland USD 12/13-2 Err:520 $ 141,877 $ 56,751 $ 85,126
375 Los Angeles Rowland USD 12/13-3 Err:520 $ 162,743 $ 65,097 $ 97,646
376 Los Angeles Rowland USD 12/13-4 Err:520 $ 140,685 $ 56,274 $ 84,411
377 Los Angeles Rowland USD 11/12-4 Err:520 $ 262,224 $ 104,890 $ 157,334 $ - ### $ -
378 Rowland USD Total $ 1,921,675 $ 768,670 $ 1,153,005 $ 1,258,400 $ 503,360 $ (755,040) $ 13,630 Err:520 Err:520 Err:520 Err:520 Err:520
379 Los Angeles San Gabriel USD 10/11-1 2012-Q4 $ - $ - $ - $ 61,731 $ 24,692 $ (37,039)
380 Los Angeles San Gabriel USD 11/12-1 Err:520 $ 47,491 $ 35,618 $ 11,873 $ - ### $ - 2
381 Los Angeles San Gabriel USD 10/11-2 2013-Q1 $ - $ - $ - $ 87,199 $ 34,880 $ (52,319)
382 Los Angeles San Gabriel USD 11/12-2 Err:520 $ 94,132 $ 37,653 $ 56,479 $ - ### $ -
383 Los Angeles San Gabriel USD 10/11-3 2013-Q2 $ - $ - $ - $ 58,713 $ 23,485 $ (35,228)
384 Los Angeles San Gabriel USD 11/12-3 Err:520 $ 67,129 $ 26,852 $ 40,277 $ - ### $ -
A B C D E F G H I J K L M N O P Q R S T U V W

Amount to release
2 to claiming unit
Amount to be recouped from DHCS Total amount
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata settlement withheld (FFY 2013 Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent check(s) and CUs in Red) or 2) Green Dot Public Schools Hacienda La Puente USD
385 Los Angeles San Gabriel USD 10/11-4 Err:520 $ 90,618 $ 36,247 $ 54,371 $ - ### $ -
386 Los Angeles San Gabriel USD 11/12-4 Err:520 $ 98,655 $ 39,462 $ 59,193 $ - ### $ -
387 San Gabriel USD Total $ 398,025 $ 175,832 $ 222,193 $ 207,643 $ 83,057 $ (124,586) $ 51,246 Err:520 Err:520 Err:520 Err:520 Err:520
388 Los Angeles Santa Clarita CCD - College of the Canyons 11/12-1 Err:520 $ 26,637 $ 25,000 $ 1,637 $ - ### $ - 2
389 Los Angeles Santa Clarita CCD - College of the Canyons 11/12-2 Err:520 $ 32,121 $ 25,000 $ 7,121 $ - ### $ - 2
390 Los Angeles Santa Clarita CCD - College of the Canyons 10/11-3 2013-Q2 $ - $ - ### $ 38,012 $ 28,509 $ (9,503) 2
391 Los Angeles Santa Clarita CCD - College of the Canyons 10/11-4 2013-Q3 $ - $ - ### $ 45,025 $ 33,769 $ (11,256) 2
392 Los Angeles Santa Clarita CCD - College of the Canyons 11/12-4 Err:520 $ 30,292 $ 25,000 $ 5,292 $ - ### $ - 2
393 Santa Clarita CCD - College of the Canyons Total $ 89,050 $ 75,000 $ 14,050 $ 83,037 $ 62,278 $ (20,759) $ 54,241 Err:520 Err:520 Err:520 Err:520 Err:520
394 Los Angeles Santa Monica - Malibu USD 10/11-2 Err:520 $ 67,898 $ 27,159 $ 40,739 $ - ### $ -
395 Santa Monica - Malibu USD Total $ 67,898 $ 27,159 $ 40,739 $ - $ - $ - $ 27,159 Err:520 Err:520 Err:520 Err:520 Err:520
396 Los Angeles Santa Monica-Malibu USD 10/11-1 2012-Q4 $ - $ - $ - $ 69,976 $ 27,990 $ (41,986)
397 Los Angeles Santa Monica-Malibu USD 11/12-1 Err:520 $ 54,212 $ 21,685 $ 32,527 $ - ### $ -
398 Los Angeles Santa Monica-Malibu USD 11/12-2 Err:520 $ 82,731 $ 33,092 $ 49,639 $ - ### $ -
399 Los Angeles Santa Monica-Malibu USD 10/11-3 2013-Q2 $ - $ - $ - $ 90,562 $ 36,225 $ (54,337)
400 Los Angeles Santa Monica-Malibu USD 11/12-3 Err:520 $ 85,004 $ 34,002 $ 51,002 $ - ### $ -
401 Los Angeles Santa Monica-Malibu USD 09/10-4 2012-Q3 $ - $ - $ - $ 79,862 $ 31,945 $ (47,917)
402 Los Angeles Santa Monica-Malibu USD 10/11-4 Err:520 $ 85,178 $ 34,071 $ 51,107 $ - ### $ -
403 Los Angeles Santa Monica-Malibu USD 11/12-4 Err:520 $ 93,845 $ 37,538 $ 56,307 $ - ### $ -
404 Santa Monica-Malibu USD Total $ 400,970 $ 160,388 $ 240,582 $ 240,400 $ 96,160 $ (144,240) $ 16,148 Err:520 Err:520 Err:520 Err:520 Err:520
405 Los Angeles Saugus USD 10/11-1 2012-Q4 $ - $ - $ - $ 65,441 $ 26,176 $ (39,265)
406 Los Angeles Saugus USD 11/12-1 Err:520 $ 57,124 $ 22,850 $ 34,274 $ - ### $ -
407 Los Angeles Saugus USD 10/11-2 2013-Q1 $ - $ - $ - $ 76,037 $ 30,415 $ (45,622)
408 Los Angeles Saugus USD 11/12-2 Err:520 $ 65,374 $ 26,150 $ 39,224 $ - ### $ -
409 Los Angeles Saugus USD 10/11-3 Err:520 $ 59,434 $ 23,774 $ 35,660 $ - ### $ -
410 Los Angeles Saugus USD 11/12-3 Err:520 $ 60,664 $ 24,266 $ 36,398 $ - ### $ -
411 Los Angeles Saugus USD 10/11-4 Err:520 $ 55,934 $ 22,374 $ 33,560 $ - ### $ -
412 Los Angeles Saugus USD 11/12-4 Err:520 $ 54,369 $ 21,748 $ 32,621 $ - ### $ -
413 Saugus USD Total $ 352,899 $ 141,162 $ 211,737 $ 141,478 $ 56,591 $ (84,887) $ 56,275 Err:520 Err:520 Err:520 Err:520 Err:520
414 Los Angeles South Whittier ESD 10/11-1 2012-Q4 $ - $ - ### $ 28,010 $ 25,000 $ (3,010) 2
415 Los Angeles South Whittier ESD 11/12-1 Err:520 $ 48,833 $ 36,625 $ 12,208 $ - ### $ - 2
416 Los Angeles South Whittier ESD 10/11-2 2013-Q1 $ - $ - $ - $ 51,519 $ 20,608 $ (30,911)
417 Los Angeles South Whittier ESD 10/11-3 2013-Q2 $ - $ - $ - $ 64,662 $ 25,865 $ (38,797)
418 Los Angeles South Whittier ESD 10/11-4 Err:520 $ 65,045 $ 26,018 $ 39,027 $ - ### $ -
419 Los Angeles South Whittier ESD 11/12-2C-1 Err:520 $ 62,230 $ 24,892 $ 37,338 $ - ### $ -
420 Los Angeles South Whittier ESD 11/12-3C-1 Err:520 $ 58,067 $ 23,227 $ 34,840 $ - ### $ -
421 Los Angeles South Whittier ESD 11/12-4C-1 Err:520 $ 63,258 $ 25,303 $ 37,955 $ - ### $ -
422 South Whittier ESD Total $ 297,433 $ 136,065 $ 161,368 $ 144,191 $ 71,473 $ (72,718) $ 63,347 Err:520 Err:520 Err:520 Err:520 Err:520
423 Los Angeles Sulphur Springs SD 10/11-1 2012-Q4 $ - $ - $ - $ 70,373 $ 28,149 $ (42,224)
424 Los Angeles Sulphur Springs SD 11/12-1 Err:520 $ 68,906 $ 27,562 $ 41,344 $ - ### $ -
425 Los Angeles Sulphur Springs SD 10/11-2 2013-Q1 $ - $ - $ - $ 82,303 $ 32,921 $ (49,382)
426 Los Angeles Sulphur Springs SD 11/12-2 Err:520 $ 65,045 $ 26,018 $ 39,027 $ - ### $ -
427 Los Angeles Sulphur Springs SD 10/11-3 2013-Q2 $ - $ - $ - $ 76,541 $ 30,616 $ (45,925)
428 Los Angeles Sulphur Springs SD 10/11-4 Err:520 $ 70,561 $ 28,224 $ 42,337 $ - ### $ -
429 Los Angeles Sulphur Springs SD 11/12-4 Err:520 $ 75,815 $ 30,326 $ 45,489 $ - ### $ -
430 Los Angeles Sulphur Springs SD 12/13-1 Err:520 $ 69,324 $ 27,730 $ 41,594
431 Los Angeles Sulphur Springs SD 11/12-3C-1 Err:520 $ 59,559 $ 23,824 $ 35,735 $ - ### $ -
432 Sulphur Springs SD Total $ 409,210 $ 163,684 $ 245,526 $ 229,217 $ 91,686 $ (137,531) $ 26,153 Err:520 Err:520 Err:520 Err:520 Err:520
433 Los Angeles Temple City USD 10/11-1 2012-Q4 $ - $ - ### $ 25,962 $ 25,000 $ (962) 2
434 Los Angeles Temple City USD 10/11-2 2013-Q1 $ - $ - ### $ 31,743 $ 25,000 $ (6,743) 2
435 Los Angeles Temple City USD 11/12-2 Err:520 $ 33,969 $ 25,477 $ 8,492 $ - ### $ - 2
436 Los Angeles Temple City USD 11/12-3 Err:520 $ 29,395 $ 25,000 $ 4,395 $ - ### $ - 2
437 Los Angeles Temple City USD 10/11-4 Err:520 $ 26,679 $ 25,000 $ 1,679 $ - ### $ - 2
438 Los Angeles Temple City USD 11/12-4 Err:520 $ 26,005 $ 25,000 $ 1,005 $ - ### $ - 2
439 Temple City USD Total $ 116,048 $ 100,477 $ 15,571 $ 57,705 $ 50,000 $ (7,705) $ 92,772 Err:520 Err:520 Err:520 Err:520 Err:520
440 Los Angeles Torrance USD 11/12-1 Err:520 $ 149,768 $ 59,907 $ 89,861 $ - ### $ -
441 Los Angeles Torrance USD 10/11-2 2013-Q1 $ - $ - ### $ 28,820 $ 25,000 $ (3,820) 2
442 Los Angeles Torrance USD 11/12-2 Err:520 $ 139,719 $ 55,888 $ 83,831 $ - ### $ -
443 Los Angeles Torrance USD 10/11-3 2013-Q2 $ - $ - ### $ 37,622 $ 28,217 $ (9,405) 2
444 Los Angeles Torrance USD 11/12-3 Err:520 $ 95,542 $ 38,217 $ 57,325 $ - ### $ -
445 Los Angeles Torrance USD 10/11-4 Err:520 $ 38,469 $ 28,852 $ 9,617 $ - ### $ - 2
446 Los Angeles Torrance USD 11/12-4 Err:520 $ 87,245 $ 34,898 $ 52,347 $ - ### $ -
447 Torrance USD Total $ 510,743 $ 217,762 $ 292,981 $ 66,442 $ 53,217 $ (13,225) $ 204,537 Err:520 Err:520 Err:520 Err:520 Err:520
448 Los Angeles Walnut Valley USD 11/12-1 Err:520 $ 30,515 $ 25,000 $ 5,515 $ - ### $ - 2
449 Los Angeles Walnut Valley USD 10/11-2 2013-Q1 $ - $ - $ - $ 100,677 $ 40,271 $ (60,406)
450 Los Angeles Walnut Valley USD 11/12-2 Err:520 $ 35,067 $ 26,300 $ 8,767 $ - ### $ - 2
451 Los Angeles Walnut Valley USD 10/11-3 Err:520 $ 88,541 $ 35,416 $ 53,125 $ - ### $ -
452 Los Angeles Walnut Valley USD 11/12-3 Err:520 $ 30,903 $ 25,000 $ 5,903 $ - ### $ - 2
453 Los Angeles Walnut Valley USD 10/11-4 Err:520 $ 86,096 $ 34,438 $ 51,658 $ - ### $ -
454 Los Angeles Walnut Valley USD 11/12-4 Err:520 $ 31,378 $ 25,000 $ 6,378 $ - ### $ - 2
455 Walnut Valley USD Total $ 302,500 $ 171,154 $ 131,346 $ 100,677 $ 40,271 $ (60,406) $ 110,748 Err:520 Err:520 Err:520 Err:520 Err:520
456 Los Angeles West Covina USD 10/11-1 2012-Q4 $ - $ - ### $ 89,124 $ 35,650 $ (53,474)
457 Los Angeles West Covina USD 10/11-2 2013-Q1 $ - $ - ### $ 114,048 $ 45,619 $ (68,429)
458 Los Angeles West Covina USD 11/12-2 Err:520 $ 115,521 $ 46,208 $ 69,313 $ - ### $ -
459 Los Angeles West Covina USD 10/11-3 2013-Q2 $ - $ - ### $ 133,709 $ 53,484 $ (80,225)
460 Los Angeles West Covina USD 11/12-3 Err:520 $ 118,028 $ 47,211 $ 70,817 $ - ### $ -
461 Los Angeles West Covina USD 10/11-4 Err:520 $ 123,148 $ 49,259 $ 73,889 $ - ### $ -
462 Los Angeles West Covina USD 11/12-4 Err:520 $ 125,075 $ 50,030 $ 75,045 $ - ### $ -
463 Los Angeles West Covina USD 11/12-1C-1 Err:520 $ 79,903 $ 31,961 $ 47,942 $ - ### $ -
464 West Covina USD Total $ 561,675 $ 224,669 $ 337,006 $ 336,881 $ 134,753 $ (202,128) $ 22,541 Err:520 Err:520 Err:520 Err:520 Err:520
465 Los Angeles Westside Union SD 10/11-1 2012-Q4 $ - $ - ### $ 122,852 $ 49,141 $ (73,711)
466 Los Angeles Westside Union SD 11/12-1 Err:520 $ 166,701 $ 66,680 $ 100,021 $ - ### $ -
467 Los Angeles Westside Union SD 10/11-2 2013-Q1 $ - $ - ### $ 76,752 $ 30,701 $ (46,051)
468 Los Angeles Westside Union SD 11/12-2 Err:520 $ 164,627 $ 65,851 $ 98,776 $ - ### $ -
469 Los Angeles Westside Union SD 10/11-3 2013-Q2 $ - $ - ### $ 61,664 $ 24,666 $ (36,998)
470 Los Angeles Westside Union SD 11/12-3 Err:520 $ 172,963 $ 69,185 $ 103,778 $ - ### $ -
471 Los Angeles Westside Union SD 09/10-4 2012-Q3 $ - $ - ### $ 62,781 $ 25,112 $ (37,669)
472 Los Angeles Westside Union SD 10/11-4 Err:520 $ 60,404 $ 24,162 $ 36,242 $ - ### $ -
473 Los Angeles Westside Union SD 11/12-4 Err:520 $ 184,640 $ 73,856 $ 110,784 $ - ### $ -
474 Westside Union SD Total $ 749,335 $ 299,734 $ 449,601 $ 324,049 $ 129,620 $ (194,429) $ 105,305 Err:520 Err:520 Err:520 Err:520 Err:520
475 Los Angeles Whittier Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 97,682 $ 39,073 $ (58,609)
476 Los Angeles Whittier Union HSD 11/12-1 Err:520 $ 143,170 $ 57,268 $ 85,902 $ - ### $ -
477 Los Angeles Whittier Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 151,409 $ 60,564 $ (90,845)
478 Los Angeles Whittier Union HSD 11/12-2 Err:520 $ 236,540 $ 94,616 $ 141,924 $ - ### $ -
479 Los Angeles Whittier Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 139,893 $ 55,957 $ (83,936)
480 Los Angeles Whittier Union HSD 11/12-3 Err:520 $ 169,742 $ 67,897 $ 101,845 $ - ### $ -
481 Los Angeles Whittier Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 143,050 $ 57,220 $ (85,830)
482 Los Angeles Whittier Union HSD 10/11-4 Err:520 $ 155,512 $ 62,205 $ 93,307 $ - ### $ -
483 Los Angeles Whittier Union HSD 11/12-4 Err:520 $ 177,429 $ 70,972 $ 106,457 $ - ### $ -
484 Whittier Union HSD Total $ 882,393 $ 352,958 $ 529,435 $ 532,034 $ 212,814 $ (319,220) $ 33,738 Err:520 Err:520 Err:520 Err:520 Err:520
485 Los Angeles William S. Hart Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 93,337 $ 37,335 $ (56,002)
486 Los Angeles William S. Hart Union HSD 11/12-1 Err:520 $ 103,024 $ 41,210 $ 61,814 $ - ### $ -
487 Los Angeles William S. Hart Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 264,950 $ 105,980 $ (158,970)
488 Los Angeles William S. Hart Union HSD 11/12-2 Err:520 $ 148,907 $ 59,563 $ 89,344 $ - ### $ -
489 Los Angeles William S. Hart Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 147,349 $ 58,940 $ (88,409)
490 Los Angeles William S. Hart Union HSD 11/12-3 Err:520 $ 195,042 $ 78,017 $ 117,025 $ - ### $ -
491 Los Angeles William S. Hart Union HSD 10/11-4 2013-Q3 $ - $ - ### $ 100,086 $ 40,034 $ (60,052)
492 Los Angeles William S. Hart Union HSD 12/13-1 Err:520 $ 79,523 $ 31,809 $ 47,714
493 Los Angeles William S. Hart Union HSD 12/13-2 Err:520 $ 67,035 $ 26,814 $ 40,221
494 Los Angeles William S. Hart Union HSD 12/13-3 Err:520 $ 81,613 $ 32,645 $ 48,968
495 Los Angeles William S. Hart Union HSD 12/13-4 Err:520 $ 87,493 $ 34,997 $ 52,496
496 Los Angeles William S. Hart Union HSD 11/12-4 Err:520 $ 221,436 $ 88,574 $ 132,862 $ - ### $ -
497 William S. Hart Union HSD Total $ 984,073 $ 393,629 $ 590,444 $ 605,722 $ 242,289 $ (363,433) $ 30,196 Err:520 Err:520 Err:520 Err:520 Err:520
498 Grand Total $ 33,454,003 $ 14,355,368 Err:502 $ 18,191,575 $ 8,659,984 $ (9,531,591) $ 4,823,777 Err:520 Err:520 Err:520 Err:520 Err:520
499 The sum of Column N equals the sum of "Column K" (Net Total) minus
500 Key Table the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
501 Column A County - Reporting LEC/LGA
502 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
503 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Pro-Rata Table
504 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed Full check amount Check Total $ 55,495 <-- Enter check total here
505 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment has not been received Sum of Net Green Err:520
506 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made Sum of Net Red $ (361,494)
507 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
A B C D E F G H I J K L M N O P Q R S T U V W

Amount to release
2 to claiming unit
Amount to be recouped from DHCS Total amount
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata settlement withheld (FFY 2013 Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent check(s) and CUs in Red) or 2) Green Dot Public Schools Hacienda La Puente USD
508 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
509 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
510 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
511 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
512 The last subtotal amount is the final amount due to/from the LEC/LGA
513 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
514 Column N The sum of Column N equals the sum of "Column K" (Net Total) minus the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
515 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
516 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
517 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
518

519 Released Claiming Unit Invoice on placeholder to be paid 100%


520

521 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
522 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
523

524 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
525 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
526 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
527 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
528

529 Claiming units no longer participating (5% reduction)


530
531 12/13 claims
532 13/14 claims
Pro-Rata Net Negative Distribution Table

County Claiming Unit Amount to be released Pro Rata Percent Golden Plains Unified Hanford Joint Union HS Riverdale Joint Unified SCCD-North Centers SCCD-Reedley College West Fresno Elementary
Madera Armona Union Elementary 10/11-1 2012-Q4 $ - $ - ### $ 45,234 $ 33,926 $ (11,308) 2
Madera Armona Union Elementary 10/11-2 2013-Q1 $ - $ - ### $ 49,326 $ 36,995 $ (12,331) 2
Madera Armona Union Elementary 11/12-3 Err:520 $ 60,394 $ 24,158 $ 36,236 $ - ### $ -
Madera Armona Union Elementary 11/12-4 Err:520 $ 66,441 $ 26,576 $ 39,865 $ - ### $ -
Madera Armona Union Elementary 10/11-3 Err:520 $ 42,999 $ 32,249 $ 10,750 $ - ### $ - 2
Madera Armona Union Elementary 11/12-1C-1 Err:520 $ 60,487 $ 24,195 $ 36,292 $ - ### $ -
Madera Armona Union Elementary 11/12-2C-1 Err:520 $ 102,949 $ 41,180 $ 61,769 $ - ### $ -
Armona Union Elementary Total* $ 333,270 $ 148,358 $ 184,912 $ 94,560 $ 70,921 $ (23,639) $ 124,719 5.29% Err:502 Err:502 $ 1,119.51 $ 715.56 $ 258.55 $ 504.35 $ 24.28 $ 214.80 $ 215.81
Madera Atwater Elementary 10/11-2 2013-Q1 $ - $ - ### $ 195,193 $ 78,077 $ (117,116)
Madera Atwater Elementary 10/11-3C2 Err:520 $ 159,882 $ 63,953 $ 95,929 $ - ### $ -
Madera Atwater Elementary 10/11-1 2012-Q4 $ - $ - ### $ 149,036 $ 59,614 $ (89,422)
Madera Atwater Elementary 10/11-4C-1 Err:520 $ 124,830 $ 49,932 $ 74,898 $ - ### $ -
Madera Atwater Elementary 11/12-2 Err:520 $ 148,398 $ 59,359 $ 89,039 $ - ### $ -
Madera Atwater Elementary 11/12-3 Err:520 $ 162,595 $ 65,038 $ 97,557 $ - ### $ -
Madera Atwater Elementary 09/10-4 2012-Q3 $ - $ - ### $ 96,550 $ 38,620 $ (57,930)
Madera Atwater Elementary 11/12-4 Err:520 $ 138,198 $ 55,279 $ 82,919 $ - ### $ -
Madera Atwater Elementary 11/12-1C-1 Err:520 $ 115,223 $ 46,089 $ 69,134 $ - ### $ -
Atwater Elementary Total* $ 849,126 $ 339,650 $ 509,476 $ 440,779 $ 176,311 $ (264,468) $ 75,182 3.19% Err:502 Err:502 $ 674.86 $ 431.35 $ 155.86 $ 304.03 $ 14.64 $ 129.49 $ 130.09
Madera Caruthers USD 10/11-2 Err:520 $ 25,018 $ 25,000 $ 18 $ - ### $ - 2
Caruthers USD Total $ 25,018 $ 25,000 $ 18 $ - $ - $ - $ 25,000 1.06% Err:502 Err:502 $ 224.41 $ 143.43 $ 51.83 $ 101.10 $ 4.87 $ 43.06 $ 43.26
Madera Chawanakee USD 10/11-1 2012-Q4 $ - $ - ### $ 35,908 $ 26,931 $ (8,977) 2
Madera Chawanakee USD 10/11-3C2 Err:520 $ 31,433 $ 25,000 $ 6,433 $ - ### $ - 2
Madera Chawanakee USD 10/11-2 2013-Q1 $ - $ - ### $ 38,129 $ 28,597 $ (9,532) 2
Chawanakee USD Total* $ 31,433.00 $ 25,000.00 $ 6,433.00 $ 74,037 $ 55,528 $ (18,509) $ 6,491 0.28% Err:502 Err:502 $ 58.27 $ 37.24 $ 13.46 $ 26.25 $ 1.26 $ 11.18 $ 11.23
Madera Chowchilla Elementary 10/11-1 2012-Q4 $ - $ - ### $ 27,618 $ 25,000 $ (2,618) 2
Madera Chowchilla Elementary 10/11-2 2013-Q1 $ - $ - ### $ 29,671 $ 25,000 $ (4,671) 2
Madera Chowchilla Elementary 11/12-2 Err:520 $ 31,839 $ 25,000 $ 6,839 $ - ### $ - 2
Madera Chowchilla Elementary 10/11-3 2013-Q2 $ - $ - ### $ 32,481 $ 25,000 $ (7,481) 2
Madera Chowchilla Elementary 11/12-3 Err:520 $ 30,927 $ 25,000 $ 5,927 $ - ### $ - 2
Madera Chowchilla Elementary 11/12-4 Err:520 $ 29,502 $ 25,000 $ 4,502 $ - ### $ - 2
Chowchilla Elementary Total $ 92,268 $ 75,000 $ 17,268 $ 89,770 $ 75,000 $ (14,770) $ 60,230 2.55% Err:502 Err:502 $ 540.64 $ 345.56 $ 124.86 $ 243.56 $ 11.72 $ 103.73 $ 104.22
Madera Chowchilla Union High 10/11-2 2013-Q1 $ - $ - ### $ 44,372 $ 33,279 $ (11,093) 2
Madera Chowchilla Union High 12/13-1 Err:520 $ 1,606 $ 1,445 $ 161
Madera Chowchilla Union High 12/13-2 Err:520 $ 3,897 $ 3,507 $ 390
Madera Chowchilla Union High 12/13-3 Err:520 $ 1,652 $ 1,487 $ 165
Madera Chowchilla Union High 13/14-1 Err:520 $ 3,645 $ 3,281 $ 364
Madera Chowchilla Union High 12/13-4 Err:520 $ 1,705 $ 1,535 $ 170
Chowchilla Union High Total $ 12,505.00 $ 11,255.00 $ 1,250.00 $ 44,372 $ 33,279 $ (11,093) $ 162 0.01% Err:502 Err:502 $ 1.45 $ 0.93 $ 0.34 $ 0.66 $ 0.03 $ 0.28 $ 0.28
Madera Coalinga-Huron Joint USD 10/11-1 2012-Q4 $ - $ - ### $ 57,335 $ 22,934 $ (34,401)
Madera Coalinga-Huron Joint USD 10/11-2 2013-Q1 $ - $ - ### $ 67,707 $ 27,083 $ (40,624)
Madera Coalinga-Huron Joint USD 11/12-2 Err:520 $ 54,192 $ 21,677 $ 32,515 $ - ### $ -
Madera Coalinga-Huron Joint USD 10/11-4C-1 Err:520 $ 27,416 $ 25,000 $ 2,416 $ - ### $ - 2
Madera Coalinga-Huron Joint USD 12/13-1 Err:520 $ 6,501 $ 5,851 $ 650
Madera Coalinga-Huron Joint USD 11/12-1C-1 Err:520 $ 33,381 $ 25,036 $ 8,345 $ - ### $ - 2
Coalinga-Huron Joint USD Total* $ 121,490 $ 77,564 $ 43,926 $ 125,042 $ 50,017 $ (75,025) $ 2,539 0.11% Err:502 Err:502 $ 22.79 $ 14.57 $ 5.26 $ 10.27 $ 0.49 $ 4.37 $ 4.39
Madera Corcoran Joint USD 10/11-1 2012-Q4 $ - $ - ### $ 88,904 $ 35,562 $ (53,342)
Madera Corcoran Joint USD 11/12-2 Err:520 $ 46,308 $ 34,731 $ 11,577 $ - ### $ - 2
Madera Corcoran Joint USD 11/12-3 Err:520 $ 46,084 $ 34,563 $ 11,521 $ - ### $ - 2
Madera Corcoran Joint USD 10/11-2-C1 Err:520 $ 39,366 $ 29,525 $ 9,841 $ - ### $ - 2
Madera Corcoran Joint Unified 10/11-3C2 Err:520 $ 45,079 $ 33,809 $ 11,270 $ - ### $ - 2
Madera Corcoran Joint USD 11/12-1C-1 Err:520 $ 45,405 $ 34,054 $ 11,351 $ - ### $ - 2
Corcoran Joint USD Total* $ 222,242 $ 166,682 $ 55,560 $ 88,904 $ 35,562 $ (53,342) $ 113,340 4.81% Err:502 Err:502 $ 1,017.37 $ 650.27 $ 234.96 $ 458.33 $ 22.06 $ 195.21 $ 196.12
Madera Cutler - Orosi Joint USD 10/11-1 2012-Q4 $ - $ - ### $ 162,411 $ 64,964 $ (97,447)
Madera Cutler - Orosi Joint USD 09/10-4 2012-Q3 $ - $ - ### $ 39,527 $ 29,645 $ (9,882) 2
Madera Cutler - Orosi Joint USD 10/11-2 2013-Q1 $ - $ - ### $ 196,026 $ 78,410 $ (117,616)
Madera Cutler - Orosi Joint USD 11/12-2 Err:520 $ 214,141 $ 85,656 $ 128,485 $ - ### $ -
Madera Cutler - Orosi Joint USD 11/12-3 Err:520 $ 80,894 $ 32,358 $ 48,536 $ - ### $ -
Madera Cutler - Orosi Joint USD 11/12-4 Err:520 $ 72,604 $ 29,042 $ 43,562 $ - ### $ -
Madera Cutler - Orosi Joint USD 10/11-3C2 Err:520 $ 49,901 $ 37,426 $ 12,475 $ - ### $ - 2
Madera Cutler-Orosi JUSD 10/11-4C-1 Err:520 $ 26,791 $ 25,000 $ 1,791 $ - ### $ - 2
Madera Cutler - Orosi Joint USD 11/12-1C-1 Err:520 $ 213,220 $ 85,288 $ 127,932 $ - ### $ -
Cutler - Orosi Joint USD Total* $ 657,551 $ 294,770 $ 362,781 $ 397,964 $ 173,019 $ (224,945) $ 69,825 2.96% Err:502 Err:502 $ 626.77 $ 400.61 $ 144.75 $ 282.36 $ 13.59 $ 120.26 $ 120.82
Madera Delhi Unified 10/11-1 2012-Q4 $ - $ - ### $ 88,399 $ 35,360 $ (53,039)
Madera Delhi Unified 09/10-4 2012-Q3 $ - $ - ### $ 43,279 $ 32,459 $ (10,820) 2
Madera Delhi Unified 10/11-2-C1 Err:520 $ 48,108 $ 36,081 $ 12,027 $ - ### $ - 2
Madera Delhi Unified 10/11-3C2 Err:520 $ 29,443 $ 25,000 $ 4,443 $ - ### $ - 2
Madera Delhi Unified 11/12-1C-1 Err:520 $ 52,461 $ 20,984 $ 31,477 $ - ### $ -
Delhi Unified Total $ 130,012 $ 82,065 $ 47,947 $ 131,678 $ 67,819 $ (63,859) $ 18,206 0.77% Err:502 Err:502 $ 163.42 $ 104.45 $ 37.74 $ 73.62 $ 3.54 $ 31.36 $ 31.50
Madera Farmersville USD 10/11-1 2012-Q4 $ - $ - ### $ 32,587 $ 25,000 $ (7,587) 2
Madera Farmersville USD 11/12-1 Err:520 $ 51,623 $ 20,649 $ 30,974 $ - ### $ -
Madera Farmersville USD 10/11-2 2013-Q1 $ - $ - ### $ 41,726 $ 31,295 $ (10,431) 2
Madera Farmersville USD 11/12-2 Err:520 $ 35,576 $ 26,682 $ 8,894 $ - ### $ - 2
Madera Farmersville USD 10/11-3 2013-Q2 $ - $ - ### $ 28,736 $ 25,000 $ (3,736) 2
Madera Farmersville USD 11/12-3 Err:520 $ 31,912 $ 25,000 $ 6,912 $ - ### $ - 2
Madera Farmersville USD 10/11-4 Err:520 $ 31,902 $ 25,000 $ 6,902 $ - ### $ - 2
Madera Farmersville USD 11/12-4 Err:520 $ 31,287 $ 25,000 $ 6,287 $ - ### $ - 2
Farmersville USD Total $ 182,300 $ 122,331 $ 59,969 $ 103,049 $ 81,295 $ (21,754) $ 100,577 4.27% Err:502 Err:502 $ 902.81 $ 577.05 $ 208.50 $ 406.72 $ 19.58 $ 173.22 $ 174.04
Madera Firebaugh Las Deltas USD 10/11-1 2012-Q4 $ - $ - ### $ 33,978 $ 25,484 $ (8,494) 2
Madera Firebaugh Las Deltas USD 11/12-1 Err:520 $ 35,576 $ 26,682 $ 8,894 $ - ### $ - 2
Madera Firebaugh Las Deltas USD 10/11-2 2013-Q1 $ - $ - ### $ 34,398 $ 25,799 $ (8,599) 2
Madera Firebaugh Las Deltas USD 11/12-2 Err:520 $ 40,509 $ 30,382 $ 10,127 $ - ### $ - 2
Madera Firebaugh Las Deltas USD 10/11-3 Err:520 $ 61,362 $ 24,545 $ 36,817 $ - ### $ -
Madera Firebaugh Las Deltas USD 11/12-3 Err:520 $ 39,624 $ 29,718 $ 9,906 $ - ### $ - 2
Madera Firebaugh Las Deltas USD 10/11-4 Err:520 $ 59,211 $ 23,684 $ 35,527 $ - ### $ -
Madera Firebaugh Las Deltas USD 11/12-4 Err:520 $ 44,877 $ 33,658 $ 11,219 $ - ### $ - 2
Firebaugh Las Deltas USD Total $ 281,159 $ 168,669 $ 112,490 $ 68,376 $ 51,283 $ (17,093) $ 151,576 6.43% Err:502 Err:502 $ 1,360.59 $ 869.65 $ 314.22 $ 612.96 $ 29.51 $ 261.06 $ 262.28
Madera Fresno COE 10/11-1 2012-Q4 $ - $ - ### $ 148,678 $ 59,471 $ (89,207)
Madera Fresno COE 10/11-2 2013-Q1 $ - $ - ### $ 206,958 $ 82,783 $ (124,175)
Madera Fresno COE 11/12-2 Err:520 $ 63,448 $ 25,379 $ 38,069 $ - ### $ -
Madera Fresno COE 11/12-3 Err:520 $ 72,414 $ 28,966 $ 43,448 $ - ### $ -
Madera Fresno COE 09/10-4 2012-Q3 $ - $ - ### $ 33,011 $ 25,000 $ (8,011) 2
Madera Fresno COE 10/11-3C2 Err:520 $ 58,976 $ 23,590 $ 35,386 $ - ### $ -
Madera Fresno COE 10/11-4C-1 Err:520 $ 52,685 $ 21,074 $ 31,611 $ - ### $ -
Madera Fresno COE 12/13-1 Err:520 $ 13,651 $ 12,286 $ 1,365
Madera Fresno COE 12/13-2 Err:520 $ 38,075 $ 28,556 $ 9,519
Madera Fresno COE 12/13-3 Err:520 $ 46,213 $ 34,660 $ 11,553
Madera Fresno COE 12/13-4 Err:520 $ 15,986 $ 14,387 $ 1,599
Madera Fresno COE 13/14-1 Err:520 $ 15,708 $ 14,137 $ 1,571
Madera Fresno COE 11/12-1C-1 Err:520 $ 51,064 $ 20,426 $ 30,638 $ - ### $ -
Fresno COE Total $ 428,220 $ 223,461 $ 204,759 $ 388,647 $ 167,254 $ (221,393) $ 2,068 0.09% Err:502 Err:502 $ 18.56 $ 11.86 $ 4.29 $ 8.36 $ 0.40 $ 3.56 $ 3.58
Madera Fresno Unified 10/11-1 2012-Q4 $ - $ - ### $ 319,918 $ 127,967 $ (191,951)
Madera Fresno Unified 11/12-1 Err:520 $ 287,481 $ 114,992 $ 172,489 $ - ### $ -
Madera Fresno Unified 09/10-2 2012-Q1 $ - $ - ### $ 426,051 $ 170,420 $ (255,631)
Madera Fresno Unified 10/11-2 2013-Q1 $ - $ - ### $ 365,914 $ 146,366 $ (219,548)
Madera Fresno Unified 11/12-2 Err:520 $ 357,040 $ 142,816 $ 214,224 $ - ### $ -
Madera Fresno Unified 10/11-3 Err:520 $ 401,930 $ 160,772 $ 241,158 $ - ### $ -
Madera Fresno Unified 11/12-3 Err:520 $ 335,999 $ 134,400 $ 201,599 $ - ### $ -
Madera Fresno Unified 09/10-4 2012-Q3 $ - $ - ### $ 313,735 $ 125,494 $ (188,241)
Madera Fresno Unified 10/11-4 Err:520 $ 390,611 $ 156,244 $ 234,367 $ - ### $ -
Madera Fresno Unified 12/13-1 Err:520 $ 192,198 $ 76,879 $ 115,319
Madera Fresno Unified 11/12-4 Err:520 $ 288,901 $ 115,560 $ 173,341 $ - ### $ -
Fresno Unified Total $ 2,254,160 $ 901,663 $ 1,352,497 $ 1,425,618 $ 570,247 $ (855,371) $ 46,292 1.96% Err:502 Err:502 $ 415.53 $ 265.59 $ 95.97 $ 187.20 $ 9.01 $ 79.73 $ 80.10
Madera Golden Plains Unified 10/11-2 2013-Q1 $ - $ - ### $ 36,963 $ 27,722 $ (9,241) 2
Madera Golden Plains Unified 10/11-3 2013-Q2 $ - $ - ### $ 43,370 $ 32,528 $ (10,842) 2
Madera Golden Plains Unified 12/13-4 Err:520 $ 4,173 $ 3,756 $ 417
Madera Golden Plains Unified 10/11-4 2013-Q3 $ - $ - ### $ 29,838 $ 25,000 $ (4,838) 2
Golden Plains Unified Total $ 4,173.00 $ 3,756.00 $ 417.00 $ 110,171 $ 85,250 $ (24,921) $ (21,165) 36.67%
Madera Golden Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 43,751 $ 30,626 $ (13,125)
Madera Golden Valley USD 11/12-2 Err:520 $ 29,065 $ 20,346 $ 8,719 $ - ### $ -
Madera Golden Valley USD 10/11-3C2 Err:520 $ 26,754 $ 18,728 $ 8,026 $ - ### $ -
Madera Golden Valley USD 11/12-1C-1 Err:520 $ 31,928 $ 22,350 $ 9,578 $ - ### $ -
Golden Valley USD Total* $ 87,747 $ 61,424 $ 26,323 $ 43,751 $ 30,626 $ (13,125) $ 48,299 2.05% Err:502 Err:502 $ 433.54 $ 277.11 $ 100.13 $ 195.31 $ 9.40 $ 83.19 $ 83.57
Madera Hanford ESD 10/11-1 2012-Q4 $ - $ - ### $ 62,628 $ 25,051 $ (37,577)
Madera Hanford ESD 11/12-1 Err:520 $ 66,651 $ 26,660 $ 39,991 $ - ### $ -
Madera Hanford ESD 10/11-2 2013-Q1 $ - $ - ### $ 83,418 $ 33,367 $ (50,051)
Madera Hanford ESD 11/12-3 Err:520 $ 70,927 $ 28,371 $ 42,556 $ - ### $ -
Madera Hanford ESD 09/10-4 2012-Q3 $ - $ - ### $ 113,582 $ 45,433 $ (68,149)
Madera Hanford ESD 10/11-4 Err:520 $ 68,508 $ 27,403 $ 41,105 $ - ### $ -
Madera Hanford ESD 11/12-4 Err:520 $ 34,016 $ 25,512 $ 8,504 $ - ### $ - 2
Madera Hanford ESD 12/13-1 Err:520 $ 13,457 $ 12,111 $ 1,346
Madera Hanford ESD 12/13-2 Err:520 $ 28,092 $ 21,069 $ 7,023
Madera Hanford ESD 10/11-3C1 Err:520 $ 75,967 $ 30,387 $ 45,580 $ - ### $ -
Hanford ESD Total $ 357,618 $ 171,513 $ 186,105 $ 259,628 $ 103,851 $ (155,777) $ 15,736 0.67% Err:502 Err:502 $ 141.25 $ 90.28 $ 32.62 $ 63.63 $ 3.06 $ 27.10 $ 27.23
Madera Hanford Joint Union HS 10/11-1 2012-Q4 $ - $ - ### $ 49,827 $ 37,370 $ (12,457) 2
Madera Hanford Joint Union HS 10/11-2 2013-Q1 $ - $ - ### $ 54,620 $ 21,848 $ (32,772)
Madera Hanford Joint Union HS 12/13-1 Err:520 $ 1,377 $ 1,239 $ 138
Madera Hanford Joint Union HS 12/13-2 Err:520 $ 187 $ 168 $ 19
Madera Hanford Joint Union HS 12/13-3 Err:520 $ 391 $ 352 $ 39
Madera Hanford Joint Union HS 12/13-4 Err:520 $ 305 $ 275 $ 30
Madera Hanford Joint Union HS 13/14-1 Err:520 $ 30 $ 27 $ 3
Madera Hanford Joint Union HS 13/14-2 Err:520 $ 95 $ 86 $ 9
Madera Hanford Joint Union HS 13/14-3 Err:520 $ 1,865 $ 1,679 $ 186
Madera Hanford Joint Union HS 13/14-4 Err:520 $ 266 $ 239 $ 27
Madera Hanford Joint Union HS 11/12-1C-1 Err:520 $ 36,848 $ 27,636 $ 9,212 $ - ### $ - 2
Hanford Joint Union HS Total $ 41,364 $ 31,701 $ 9,663 $ 104,447 $ 59,218 $ (45,229) $ (13,528) 23.44%
Madera Hilmar USD 10/11-1 2012-Q4 $ - $ - ### $ 52,709 $ 21,084 $ (31,625)
Madera Hilmar USD 09/10-4 2012-Q3 $ - $ - ### $ 44,918 $ 33,689 $ (11,229) 2
Madera Hilmar USD 10/11-1R-1 2012-Q4 $ - $ - ### $ 53,554 $ 21,422 $ (32,132)
Madera Hilmar Unified 10/11-2-C1 Err:520 $ 54,791 $ 21,916 $ 32,875 $ - ### $ -
Madera Hilmar Unified 10/11-3C2 Err:520 $ 34,407 $ 25,805 $ 8,602 $ - ### $ - 2
Madera Hilmar USD 11/12-2C-1 Err:520 $ 43,751 $ 32,813 $ 10,938 $ - ### $ - 2
Madera Hilmar USD 11/12-3C-1 Err:520 $ 41,179 $ 30,884 $ 10,295 $ - ### $ - 2
Hilmar USD Total* $ 174,128 $ 111,418 $ 62,710 $ 151,181 $ 76,195 $ (74,986) $ 36,432 1.55% Err:502 Err:502 $ 327.02 $ 209.02 $ 75.53 $ 147.33 $ 7.09 $ 62.75 $ 63.04
Madera Kerman USD 11/12-1 Err:520 $ 55,975 $ 22,390 $ 33,585 $ - ### $ -
Madera Kerman USD 10/11-2 2013-Q1 $ - $ - ### $ 72,280 $
Total amount
Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Amount to release 2013 and CUs in Option (insert 1 Kings River-Hardwick Union
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent to claiming unit Red) or 2) Golden Plains Unified Hanford Joint Union HS Elem. Riverdale Joint Unified SCCD-North Centers SCCD-Reedley College West Fresno Elementary
Madera Kings COE 11/12-1C-1 Err:520 $ 52,056 $ 20,822 $ 31,234 $ - ### $ -
Kings COE Total $ 290,851 $ 188,563 $ 102,288 $ 93,447 $ 37,379 $ (56,068) $ 132,495 5.62% Err:502 Err:502 $ 1,189.31 $ 760.17 $ 274.67 $ 535.80 $ 25.79 $ 228.20 $ 229.27
Madera Kings River-Hardwick Union Elementary 10/11-1 2012-Q4 $ - $ - ### $ 26,535 $ 25,000 $ (1,535) 2
Madera Kings River-Hardwick Union Elementary 10/11-2 2013-Q1 $ - $ - ### $ 28,353 $ 25,000 $ (3,353) 2
Kings River-Hardwick Union Elementary Total $ - $ - $ - $ 54,888 $ 50,000 $ (4,888) $ (4,888) 8.47%
Madera Kingsburg Elementary Charter 11/12-1 Err:520 $ 29,327 $ 25,000 $ 4,327 $ - ### $ - 2
Madera Kingsburg Elementary Charter 10/11-2 2013-Q1 $ - $ - ### $ 33,662 $ 25,247 $ (8,415) 2
Madera Kingsburg Elementary Charter 10/11-4 Err:520 $ 47,968 $ 35,976 $ 11,992 $ - ### $ - 2
Madera Kingsburg Elementary Charter 11/12-2 Err:520 $ 44,918 $ 33,689 $ 11,229 $ - ### $ - 2
Madera Kingsburg Elementary Charter 11/12-3 Err:520 $ 40,556 $ 30,417 $ 10,139 $ - ### $ - 2
Madera Kingsburg Elementary Charter 11/12-4 Err:520 $ 45,740 $ 34,305 $ 11,435 $ - ### $ - 2
Kingsburg Elementary Charter Total* $ 208,509 $ 159,387 $ 49,122 $ 33,662 $ 25,247 $ (8,415) $ 150,972 6.40% Err:502 Err:502 $ 1,355.17 $ 866.18 $ 312.97 $ 610.51 $ 29.39 $ 260.02 $ 261.24
Madera Lindsay USD 10/11-1 2012-Q4 $ - $ - ### $ 63,168 $ 25,267 $ (37,901)
Madera Lindsay USD 10/11-2 2013-Q1 $ - $ - ### $ 65,415 $ 26,166 $ (39,249)
Madera Lindsay USD 11/12-2 Err:520 $ 114,122 $ 45,649 $ 68,473 $ - ### $ -
Madera Lindsay USD 10/11-3 Err:520 $ 73,379 $ 29,352 $ 44,027 $ - ### $ -
Madera Lindsay USD 11/12-3 Err:520 $ 64,057 $ 25,623 $ 38,434 $ - ### $ -
Madera Lindsay USD 09/10-4 2012-Q3 $ - $ - ### $ 34,719 $ 26,039 $ (8,680) 2
Madera Lindsay USD 10/11-4 Err:520 $ 57,315 $ 22,926 $ 34,389 $ - ### $ -
Madera Lindsay USD 11/12-4 Err:520 $ 98,224 $ 39,290 $ 58,934 $ - ### $ -
Madera Lindsay USD 11/12-1C-1 Err:520 $ 62,953 $ 25,181 $ 37,772 $ - ### $ -
Lindsay USD Total $ 470,050 $ 188,021 $ 282,029 $ 163,302 $ 77,472 $ (85,830) $ 102,191 4.33% Err:502 Err:502 $ 917.30 $ 586.31 $ 211.85 $ 413.25 $ 19.89 $ 176.00 $ 176.83
Madera Los Banos USD 11/12-1 Err:520 $ 109,286 $ 43,714 $ 65,572 $ - ### $ -
Madera Los Banos USD 10/11-2 2013-Q1 $ - $ - ### $ 72,369 $ 28,948 $ (43,421)
Madera Los Banos USD 11/12-2 Err:520 $ 117,373 $ 46,949 $ 70,424 $ - ### $ -
Madera Los Banos USD 10/11-3 Err:520 $ 46,110 $ 34,583 $ 11,527 $ - ### $ - 2
Madera Los Banos USD 11/12-3 Err:520 $ 101,674 $ 40,670 $ 61,004 $ - ### $ -
Madera Los Banos USD 09/10-4 2012-Q3 $ - $ - ### $ 75,185 $ 30,074 $ (45,111)
Madera Los Banos USD 10/11-4 Err:520 $ 64,961 $ 25,984 $ 38,977 $ - ### $ -
Madera Los Banos USD 11/12-4 Err:520 $ 114,322 $ 45,729 $ 68,593 $ - ### $ -
Los Banos USD Total $ 553,726 $ 237,629 $ 316,097 $ 147,554 $ 59,022 $ (88,532) $ 149,097 6.32% Err:502 Err:502 $ 1,338.34 $ 855.42 $ 309.09 $ 602.93 $ 29.02 $ 256.79 $ 257.99
Madera Madera Unified 10/11-1 2012-Q4 $ - $ - ### $ 49,535 $ 37,151 $ (12,384) 2
Madera Madera Unified 10/11-3C2 Err:520 $ 28,017 $ 25,000 $ 3,017 $ - ### $ - 2
Madera Madera Unified 11/12-1C-1 Err:520 $ 30,725 $ 25,000 $ 5,725 $ - ### $ - 2
Madera Madera Unified 10/11-2 2013-Q1 $ - $ - ### $ 52,438 $ 20,975 $ (31,463)
Madera Madera Unified 11/12-2 Err:520 $ 59,262 $ 23,705 $ 35,557 $ - ### $ -
Madera Unified Total $ 118,004 $ 73,705 $ 44,299 $ 101,973 $ 58,126 $ (43,847) $ 29,858 1.27% Err:502 Err:502 $ 268.01 $ 171.31 $ 61.90 $ 120.74 $ 5.81 $ 51.42 $ 51.67
Madera Madera Career and Alt ED 09/10-4 2012-Q3 $ - $ - ### $ 32,806 $ 25,000 $ (7,806) 2
Madera Career and Alt ED Total $ - $ - $ - $ 32,806 $ 25,000 $ (7,806) $ - N/A
Madera Madera COE 10/11-1 2012-Q4 $ - $ - ### $ 147,246 $ 58,898 $ (88,348)
Madera Madera COE 11/12-2 Err:520 $ 71,927 $ 28,771 $ 43,156 $ - ### $ -
Madera Madera COE 11/12-3 Err:520 $ 61,378 $ 24,551 $ 36,827 $ - ### $ -
Madera Madera COE 11/12-4 Err:520 $ 58,594 $ 23,438 $ 35,156 $ - ### $ -
Madera Madera COE 10/11-2-C1 Err:520 $ 83,026 $ 33,210 $ 49,816 $ - ### $ -
Madera Madera COE 10/11-3C2 Err:520 $ 50,720 $ 20,288 $ 30,432 $ - ### $ -
Madera Madera COE 10/11-4C-1 Err:520 $ 46,026 $ 34,520 $ 11,506 $ - ### $ - 2
Madera Madera COE 11/12-1C-1 Err:520 $ 69,300 $ 27,720 $ 41,580 $ - ### $ -
Madera COE Total $ 440,971 $ 192,498 $ 248,473 $ 147,246 $ 58,898 $ (88,348) $ 96,344 4.09% Err:502 Err:502 $ 864.81 $ 552.76 $ 199.73 $ 389.60 $ 18.75 $ 165.93 $ 166.71
Madera Mariposa County Unified 10/11-2 2013-Q1 $ - $ - ### $ 30,469 $ 25,000 $ (5,469) 2
Madera Mariposa County Unified 11/12-2 Err:520 $ 26,180 $ 25,000 $ 1,180 $ - ### $ - 2
Mariposa County Unified Total $ 26,180 $ 25,000 $ 1,180 $ 30,469 $ 25,000 $ (5,469) $ 19,531 0.83% Err:502 Err:502 $ 175.32 $ 112.06 $ 40.49 $ 78.98 $ 3.80 $ 33.64 $ 33.80
Madera Merced Career & Alt Ed 10/11-1 2012-Q4 $ - $ - ### $ 63,170 $ 25,268 $ (37,902)
Madera Merced Career & Alt Ed 10/11-2 2013-Q1 $ - $ - ### $ 39,750 $ 29,813 $ (9,937) 2
Merced Career & Alt Ed Total $ - $ - $ - $ 102,920 $ 55,081 $ (47,839) $ - N/A
Madera Merced City Elementary Schools 11/12-1 Err:520 $ 27,182 $ 25,000 $ 2,182 $ - ### $ - 2
Madera Merced City Elementary Schools 10/11-2 2013-Q1 $ - $ - ### $ 30,964 $ 25,000 $ (5,964) 2
Merced City Elementary SD 10/11-1 2012-Q4 $ - $ - ### $ 35,928 $ 26,946 $ (8,982) 2
Madera Merced City Elementary Schools 11/12-2 Err:520 $ 33,978 $ 25,484 $ 8,494 $ - ### $ - 2
Madera Merced City Elementary Schools 11/12-4 Err:520 $ 31,481 $ 25,000 $ 6,481 $ - ### $ - 2
Merced City Elementary Schools Total* $ 92,641 $ 75,484 $ 17,157 $ 66,892 $ 51,946 $ (14,946) $ 60,538 2.57% Err:502 Err:502 $ 543.41 $ 347.33 $ 125.50 $ 244.81 $ 11.78 $ 104.27 $ 104.75
Madera Merced City ESD 10/11-4 Err:520 $ 29,608 $ 25,000 $ 4,608 $ - ### $ - 2
Merced City ESD Total* $ 29,608 $ 25,000 $ 4,608 $ - $ - $ - $ 25,000 1.06% Err:502 Err:502 $ 224.41 $ 143.43 $ 51.83 $ 101.10 $ 4.87 $ 43.06 $ 43.26
Madera Merced COE 11/12-2 Err:520 $ 120,661 $ 48,264 $ 72,397 $ - ### $ -
Madera Merced COE 11/12-3 Err:520 $ 154,944 $ 61,978 $ 92,966 $ - ### $ -
Madera Merced COE 09/10-4 2012-Q3 $ - $ - ### $ 28,357 $ 25,000 $ (3,357) 2
Madera Merced COE 11/12-4 Err:520 $ 93,713 $ 37,485 $ 56,228 $ - ### $ -
Madera Merced COE 10/11-1C-1 2012-Q4 $ - $ - ### $ 133,464 $ 53,386 $ (80,078)
Madera Merced COE 10/11-2-C1 Err:520 $ 78,799 $ 31,520 $ 47,279 $ - ### $ -
Madera Merced COE 10/11-3C2 Err:520 $ 50,725 $ 20,290 $ 30,435 $ - ### $ -
Madera Merced COE 10/11-4C-1 Err:520 $ 34,747 $ 26,060 $ 8,687 $ - ### $ - 2
Madera Merced COE 11/12-1C-1 Err:520 $ 131,452 $ 52,581 $ 78,871 $ - ### $ -
Merced COE Total $ 665,041 $ 278,178 $ 386,863 $ 161,821 $ 78,386 $ (83,435) $ 146,904 6.23% Err:502 Err:502 $ 1,318.65 $ 842.84 $ 304.54 $ 594.06 $ 28.60 $ 253.01 $ 254.20
Madera Merced Community College- Child Dev. Center 11/12-2 Err:520 $ 31,334 $ 25,000 $ 6,334 $ - ### $ - 2
Madera Merced Community College- Child Dev. Center 11/12-3 Err:520 $ 28,471 $ 25,000 $ 3,471 $ - ### $ - 2
Madera Merced Community College- Child Dev. Center 11/12-4 Err:520 $ 29,112 $ 25,000 $ 4,112 $ - ### $ - 2
Merced Community College- Child Dev. Center Total $ 88,917 $ 75,000 $ 13,917 $ - $ - $ - $ 75,000 3.18% Err:502 Err:502 $ 673.22 $ 430.30 $ 155.48 $ 303.29 $ 14.60 $ 129.17 $ 129.78
Madera Merced Union High 10/11-1 2012-Q4 $ - $ - ### $ 248,599 $ 99,440 $ (149,159)
Madera Merced Union High 11/12-2 Err:520 $ 81,750 $ 32,700 $ 49,050 $ - ### $ -
Madera Merced Union High 11/12-3 Err:520 $ 66,351 $ 26,540 $ 39,811 $ - ### $ -
Madera Merced Union High 09/10-4 2012-Q3 $ - $ - ### $ 88,312 $ 35,325 $ (52,987)
Madera Merced Union High 11/12-4 Err:520 $ 26,575 $ 25,000 $ 1,575 $ - ### $ - 2
Madera Merced Union High 10/11-2-C1 Err:520 $ 120,302 $ 48,121 $ 72,181 $ - ### $ -
Madera Merced Union High 10/11-3C2 Err:520 $ 68,112 $ 27,245 $ 40,867 $ - ### $ -
Madera Merced Union High 10/11-4C-1 Err:520 $ 42,180 $ 31,635 $ 10,545 $ - ### $ - 2
Madera Merced Union High 11/12-1C-1 Err:520 $ 41,669 $ 31,252 $ 10,417 $ - ### $ - 2
Merced Union High Total* $ 446,939 $ 222,493 $ 224,446 $ 336,911 $ 134,765 $ (202,146) $ 20,347 0.86% Err:502 Err:502 $ 182.64 $ 116.74 $ 42.18 $ 82.28 $ 3.96 $ 35.04 $ 35.21
Madera Orange Center Elementary 11/12-2 Err:520 $ 25,290 $ 25,000 $ 290 $ - ### $ - 2
Orange Center Elementary Total $ 25,290 $ 25,000 $ 290 $ - $ - $ - $ 25,000 1.06% Err:502 Err:502 $ 224.41 $ 143.43 $ 51.83 $ 101.10 $ 4.87 $ 43.06 $ 43.26
Madera Parlier Unified 10/11-1 2012-Q4 $ - $ - ### $ 59,005 $ 23,602 $ (35,403)
Madera Parlier Unified 11/12-2 Err:520 $ 66,128 $ 26,451 $ 39,677 $ - ### $ -
Madera Parlier Unified 11/12-3 Err:520 $ 75,896 $ 30,358 $ 45,538 $ - ### $ -
Madera Parlier Unified 11/12-4 Err:520 $ 53,456 $ 21,382 $ 32,074 $ - ### $ -
Madera Parlier SD 10/11-4C-1 Err:520 $ 28,201 $ 25,000 $ 3,201 $ - ### $ - 2
Madera Parlier Unified 10/11-2-C1 Err:520 $ 48,728 $ 36,546 $ 12,182 $ - ### $ - 2
Madera Parlier Unified 10/11-3C2 Err:520 $ 50,260 $ 20,104 $ 30,156 $ - ### $ -
Madera Parlier Unified 11/12-1C-1 Err:520 $ 41,598 $ 31,199 $ 10,399 $ - ### $ - 2
Parlier Unified Total* $ 364,267 $ 191,040 $ 173,227 $ 59,005 $ 23,602 $ (35,403) $ 155,637 6.60% Err:502 Err:502 $ 1,397.04 $ 892.95 $ 322.64 $ 629.38 $ 30.30 $ 268.06 $ 269.31
Madera Planada ESD 10/11-1 2012-Q4 $ - $ - ### $ 31,033 $ 25,000 $ (6,033) 2
Madera Planada ESD 12/13-1 Err:520 $ 2,547 $ 2,292 $ 255
Madera Planada ESD 12/13-2 Err:520 $ 1,696 $ 1,526 $ 170
Madera Planada ESD 12/13-3 Err:520 $ 5,432 $ 4,889 $ 543
Planada ESD Total $ 9,675.00 $ 8,707.00 $ 968.00 $ 31,033 $ 25,000 $ (6,033) $ 2,674 0.11% Err:502 Err:502 $ 24.00 $ 15.34 $ 5.54 $ 10.81 $ 0.52 $ 4.61 $ 4.63
Madera Reef - Sunset USD 11/12-2C-1 Err:520 $ 75,916 $ 30,366 $ 45,550 $ - ### $ -
Madera Reef - Sunset USD 11/12-3C-1 Err:520 $ 32,937 $ 25,000 $ 7,937 $ - ### $ - 2
Reef - Sunset USD Total $ 108,853 $ 55,366 $ 53,487 $ - $ - $ - $ 55,366 2.35% Err:502 Err:502 $ 496.98 $ 317.65 $ 114.78 $ 223.89 $ 10.78 $ 95.36 $ 95.80
Madera Riverdale Joint Unified 10/11-1 2012-Q4 $ - $ - ### $ 39,736 $ 29,802 $ (9,934) 2
Madera Riverdale Joint Unified 12/13-1 Err:520 $ 71 $ 64 $ 7
Madera Riverdale Joint Unified 12/13-2 Err:520 $ 335 $ 302 $ 33
Madera Riverdale Joint Unified 12/13-3 Err:520 $ 37 $ 33 $ 4
Riverdale Joint Unified Total $ 443.00 $ 399.00 $ 44.00 $ 39,736 $ 29,802 $ (9,934) $ (9,535) 16.52%
Madera Sanger USD 10/11-1 2012-Q4 $ - $ - ### $ 76,692 $ 30,677 $ (46,015)
Madera Sanger USD 11/12-1 Err:520 $ 58,887 $ 23,555 $ 35,332 $ - ### $ -
Madera Sanger USD 10/11-2 2013-Q1 $ - $ - ### $ 121,180 $ 48,472 $ (72,708)
Madera Sanger USD 11/12-2 Err:520 $ 122,206 $ 48,882 $ 73,324 $ - ### $ -
Madera Sanger USD 10/11-3 2013-Q2 $ - $ - ### $ 103,651 $ 41,460 $ (62,191)
Madera Sanger USD 11/12-3 Err:520 $ 125,503 $ 50,201 $ 75,302 $ - ### $ -
Madera Sanger USD 09/10-4 2012-Q3 $ - $ - ### $ 139,315 $ 55,726 $ (83,589)
Madera Sanger USD 10/11-4 Err:520 $ 115,006 $ 46,002 $ 69,004 $ - ### $ -
Madera Sanger USD 12/13-1 Err:520 $ 61,424 $ 24,570 $ 36,854
Madera Sanger USD 12/13-2 Err:520 $ 94,324 $ 37,730 $ 56,594
Madera Sanger USD 11/12-4 Err:520 $ 132,037 $ 52,815 $ 79,222 $ - ### $ -
Sanger USD Total $ 709,387 $ 283,755 $ 425,632 $ 440,838 $ 176,335 $ (264,503) $ 19,252 0.82% Err:502 Err:502 $ 172.81 $ 110.46 $ 39.91 $ 77.85 $ 3.75 $ 33.16 $ 33.31
Madera SCCCD - Fresno City College 10/11-1 2012-Q4 $ - $ - ### $ 93,472 $ 37,389 $ (56,083)
Madera SCCCD - Fresno City College 10/11-2 2013-Q1 $ - $ - ### $ 83,829 $ 33,532 $ (50,297)
Madera SCCCD - Fresno City College 11/12-1C-1 Err:520 $ 28,978 $ 25,000 $ 3,978 $ - ### $ - 2
Madera SCCCD - Fresno City College 11/12-2C-1 Err:520 $ 36,731 $ 27,548 $ 9,183 $ - ### $ - 2
Madera SCCCD - Fresno City College 11/12-3C-1 Err:520 $ 39,555 $ 29,666 $ 9,889 $ - ### $ - 2
Madera SCCCD - Fresno City College 11/12-4C-1 Err:520 $ 37,135 $ 27,851 $ 9,284 $ - ### $ - 2
SCCCD - Fresno City College Total $ 142,399 $ 110,065 $ 32,334 $ 177,301 $ 70,921 $ (106,380) $ 3,685 0.16% Err:502 Err:502 $ 33.08 $ 21.14 $ 7.64 $ 14.90 $ 0.72 $ 6.35 $ 6.38
Madera SCCCD - North Centers 10/11-1 2012-Q4 $ - $ - ### $ 25,459 $ 25,000 $ (459) 2
SCCCD - North Centers Total $ - $ - $ - $ 25,459 $ 25,000 $ (459) $ (459) 0.80%
Madera SCCCD - Reedley College 10/11-1 2012-Q4 $ - $ - ### $ 43,811 $ 32,858 $ (10,953) 2
Madera SCCCD - Reedley College 10/11-2 2013-Q1 $ - $ - ### $ 120,666 $ 48,266 $ (72,400)
Madera SCCCD - Reedley College 12/13-1 Err:520 $ 7,645 $ 6,881 $ 764
Madera SCCCD - Reedley College 12/13-2 Err:520 $ 7,593 $ 6,834 $ 759
Madera SCCCD - Reedley College 12/13-3 Err:520 $ 6,632 $ 5,969 $ 663
Madera SCCCD - Reedley College 12/13-4 Err:520 $ 5,003 $ 4,503 $ 500
Madera SCCCD - Reedley College 13/14-1 Err:520 $ 18,508 $ 16,657 $ 1,851
Madera SCCCD - Reedley College 13/14-2 Err:520 $ 4,273 $ 3,846 $ 427
Madera SCCCD - Reedley College 13/14-3 Err:520 $ 4,365 $ 3,929 $ 436
Madera SCCCD - Reedley College 13/14-4 Err:520 $ 6,303 $ 5,673 $ 630
Madera SCCCD - Reedley College 11/12-2 Err:520 $ 30,300 $ 25,000 $ 5,300 $ - ### $ - 2
SCCCD - Reedley College Total $ 90,622 $ 79,292 $ 11,330 $ 164,477 $ 81,124 $ (83,353) $ (4,061) 7.04%
Madera Washington Unified 11/12-3 Err:520 $ 32,171 $ 25,000 $ 7,171 $ - ### $ - 2
Madera Washington Unified 11/12-1C-1 Err:520 $ 27,095 $ 25,000 $ 2,095 $ - ### $ - 2
Washington Unified Total $ 59,266 $ 50,000 $ 9,266 $ - $ - $ - $ 50,000 2.12% Err:502 Err:502 $ 448.81 $ 286.87 $ 103.65 $ 202.19 $ 9.73 $ 86.12 $ 86.52
Madera Weaver Union 10/11-1 2012-Q4 $ - $ - ### $ 76,146 $ 26,651 $
A B C D E F G H I J K L M N O P Q R S T U V

2 Total amount
Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Amount to release 2013 and CUs in Option (insert 1 Kings River-Hardwick Union
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent to claiming unit Red) or 2) Golden Plains Unified Hanford Joint Union HS Elem. Riverdale Joint Unified SCCD-North Centers SCCD-Reedley College West Fresno Elementary
338 Grand Total Madera LEC Err:502 Err:502 Err:502 $ 7,010,392 $ 3,374,710 $ (3,635,682) Err:502 100% Err:502 Err:502 $ 21,165 $ 13,528 $ 4,888 $ 9,535 $ 459 $ 4,061 $ 4,080
339 The sum of Column N equals the sum of "Column K" (Net Total) minus
340 the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
341 Column A County - Reporting LEC/LGA
342 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
343 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Pro-Rata Table
344 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed Check Total Err:502 <-- Enter check total here
345 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment Sum of Net Green $ 2,357,878
346 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made Sum of Net Red $ (57,716)
347 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
348 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
349 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
350 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
351 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
352 The last subtotal amount is the final amount due to/from the LEC/LGA
353 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
354 Column N The sum of Column N equals the sum of "Column K" (Net Total) minus the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
355 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
356 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
357 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
358

359 Released Claiming Unit Invoice on placeholder to be paid 100%


360

361 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
362 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
363

364 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
365 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
366 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
367 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
368

369 Claiming units no longer participating (5% reduction)


370
371 12/13 claims
372 13/14 claims
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Orange Anaheim City SD 10/11-1 2012-Q4 $ - $ - ### $ 131,712 $ 131,712 $ -
3 Orange Anaheim City SD 10/11-2 2013-Q1 $ - $ - ### $ 103,640 $ 103,640 $ -
4 Orange Anaheim City SD 09/10-3 2012-Q2 $ - $ - ### $ 101,326 $ 101,326 $ -
5 Orange Anaheim City SD 10/11-3 2013-Q2 $ - $ - ### $ 187,822 $ 187,822 $ -
6 Orange Anaheim City SD 09/10-4 2012-Q3 $ - $ - ### $ 126,386 $ 126,386 $ -
7 Orange Anaheim City SD 11/12-4 Err:520 $ 141,732 $ 141,732 $ - $ - ### $ - 4174
8 Anaheim City SD Total $ 141,732 $ 141,732 $ - $ 650,886 $ 650,886 $ - $ 141,732
9 Orange Anaheim Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 108,203 $ 43,281 $ (64,922)
10 Orange Anaheim Union HSD 10/11-4 Err:520 $ 162,960 $ 65,184 $ 97,776 $ - ### $ - 1215
11 Orange Anaheim Union HSD 11/12-1 Err:520 $ 94,911 $ 37,964 $ 56,947 $ - ### $ - 1834
12 Orange Anaheim Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 170,382 $ 68,153 $ (102,229)
13 Orange Anaheim Union HSD 11/12-2 Err:520 $ 144,172 $ 57,669 $ 86,503 $ - ### $ - 2603
14 Orange Anaheim Union HSD 09/10-3 2012-Q2 $ - $ - ### $ 124,598 $ 49,839 $ (74,759)
15 Orange Anaheim Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 147,765 $ 59,106 $ (88,659)
16 Orange Anaheim Union HSD 11/12-3 Err:520 $ 140,319 $ 56,128 $ 84,191 $ - ### $ - 3408
17 Orange Anaheim Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 137,573 $ 55,029 $ (82,544)
18 Orange Anaheim Union HSD 12/13-1 Err:520 $ 54,318 $ 21,727 $ 32,591 4937
19 Orange Anaheim Union HSD 12/13-2 Err:520 $ 77,014 $ 30,806 $ 46,208 5733
20 Orange Anaheim Union HSD 12/13-3 Err:520 $ 104,799 $ 41,920 $ 62,879 6522
21 Orange Anaheim Union HSD 12/13-4 Err:520 $ 80,568 $ 32,227 $ 48,341
22 Orange Anaheim Union HSD 13/14-1 Err:520 $ 43,811 $ 32,858 $ 10,953
23 Orange Anaheim Union HSD 11/12-4 Err:520 $ 140,367 $ 56,147 $ 84,220 $ - ### $ - 4175
24 Anaheim Union HSD Total* $ 1,043,239 $ 432,630 $ 610,609 $ 688,521 $ 275,408 $ (413,113) $ 19,517
25 Orange Buena Park SD 11/12-1 Err:520 $ 53,847 $ 21,539 $ 32,308 $ - ### $ - 1836
26 Orange Buena Park ESD 10/11-1 2012-Q4 $ - $ - ### $ 47,988 $ 35,991 $ (11,997) 1
27 Orange Buena Park ESD 09/10-4 2012-Q3 $ - $ - ### $ 82,810 $ 33,124 $ (49,686)
28 Orange Buena Park ESD 11/12-4 Err:520 $ 65,613 $ 26,245 $ 39,368 $ - ### $ - 4177
29 Orange Buena Park SD 10/11-2 2013-Q1 $ - $ - ### $ 80,244 $ 32,098 $ (48,146)
30 Orange Buena Park SD 11/12-2 Err:520 $ 70,126 $ 28,050 $ 42,076 $ - ### $ - 2605
31 Orange Buena Park SD 10/11-3 2013-Q2 $ - $ - ### $ 82,166 $ 32,866 $ (49,300)
32 Orange Buena Park SD 12/13-1 Err:520 $ 24,980 $ 22,482 $ 2,498 4939
33 Orange Buena Park SD 11/12-3 Err:520 $ 73,631 $ 29,452 $ 44,179 $ - ### $ - 3410
34 Orange Buena Park SD 10/11-4 Err:520 $ 91,842 $ 36,737 $ 55,105 $ - ### $ - 1217
35 Buena Park SD Total* $ 380,039 $ 164,505 $ 215,534 $ 293,208 $ 134,079 $ (159,129) $ 5,376
36 Orange Calexico Union SD 10/11-3 Err:520 $ 31,886 $ 23,915 $ 7,971 $ - ### $ - 1 800
37 Orange Calexico Union SD 09/10-4 2012-Q3 $ - $ - ### $ 30,797 $ 23,098 $ (7,699) 1
38 Calexico Union SD Total $ 31,886.00 $ 23,915.00 $ 7,971.00 $ 30,797 $ 23,098 $ (7,699) $ 16,216
39 Orange Capistrano USD 10/11-1 2012-Q4 $ - $ - ### $ 167,777 $ 167,777 $ -
40 Orange Capistrano USD 10/11-2 2013-Q1 $ - $ - ### $ 248,372 $ 248,372 $ -
41 Orange Capistrano USD 09/10-4 2012-Q3 $ - $ - ### $ 140,678 $ 140,678 $ -
42 Orange Capistrano USD 11/12-4 Err:520 $ 240,338 $ 240,338 $ - $ - ### $ - 4180
43 Capistrano USD Total $ 240,338 $ 240,338 $ - $ 556,827 $ 556,827 $ - $ 240,338
44 Orange Centralia ESD 10/11-1 2012-Q4 $ - $ - ### $ 38,664 $ 28,998 $ (9,666) 2
45 Orange Centralia ESD 11/12-1 Err:520 $ 39,131 $ 29,348 $ 9,783 $ - ### $ - 2 1840
46 Orange Centralia ESD 10/11-2 2013-Q1 $ - $ - ### $ 87,333 $ 34,933 $ (52,400)
47 Orange Centralia ESD 11/12-2 Err:520 $ 82,932 $ 33,173 $ 49,759 $ - ### $ - 2609
48 Orange Centralia ESD 10/11-3 2013-Q2 $ - $ - ### $ 82,299 $ 32,920 $ (49,379)
49 Orange Centralia ESD 11/12-3 Err:520 $ 81,125 $ 32,450 $ 48,675 $ - ### $ - 3413
50 Orange Centralia ESD 09/10-4 2012-Q3 $ - $ - ### $ 107,550 $ 43,020 $ (64,530)
51 Orange Centralia ESD 10/11-4 Err:520 $ 54,155 $ 21,662 $ 32,493 $ - ### $ - 1220
52 Orange Centralia ESD 12/13-1 Err:520 $ 27,337 $ 20,503 $ 6,834 4944
53 Orange Centralia ESD 12/13-2 Err:520 $ 47,749 $ 35,812 $ 11,937 5739
54 Orange Centralia ESD 11/12-4 Err:520 $ 68,561 $ 27,424 $ 41,137 $ - ### $ - 4181
55 Centralia ESD Total $ 400,990 $ 200,372 $ 200,618 $ 315,846 $ 139,871 $ (175,975) $ 24,397
56 Orange Escondido Union SD 11/12-2 Err:520 $ 28,961 $ 28,961 $ - $ - ### $ - 2610, 2500, 2504 2500 2504
57 3414 Escondido Union SD 11/12-3 Err:520 $ 37,862 $ 37,862 $ - $ - ### $ - 3414 $ 2,848 $ 1,113
58 Orange Escondido Union SD 11/12-4 Err:520 $ 30,730 $ 30,730 $ - $ - ### $ - 4183
59 Escondido Union SD Total $ 97,553 $ 97,553 $ - $ - $ - $ - $ 97,553
60 Orange Fountain Valley School District 11/12-1 Err:520 $ 30,885 $ 25,000 $ 5,885 $ - ### $ - 2 1841
61 Orange Fountain Valley School District 10/11-2 2013-Q1 $ - $ - ### $ 54,588 $ 21,835 $ (32,753)
62 Orange Fountain Valley School District 11/12-2 Err:520 $ 68,926 $ 27,570 $ 41,356 $ - ### $ - 2611
63 Orange Fountain Valley School District 10/11-3 2013-Q2 $ - $ - ### $ 64,555 $ 25,822 $ (38,733)
64 Orange Fountain Valley School District 11/12-3 Err:520 $ 51,320 $ 20,528 $ 30,792 $ - ### $ - 3415
65 Orange Fountain Valley School District 09/10-4 2012-Q3 $ - $ - ### $ 45,714 $ 34,286 $ (11,428) 2
66 Orange Fountain Valley School District 10/11-4 Err:520 $ 75,018 $ 30,007 $ 45,011 $ - ### $ - 1221
67 Orange Fountain Valley School District 11/12-4 Err:520 $ 54,757 $ 21,903 $ 32,854 $ - ### $ - 4184
68 Fountain Valley School District Total $ 280,906 $ 125,008 $ 155,898 $ 164,857 $ 81,943 $ (82,914) $ 42,094
69 Orange Fullerton ESD 11/12-1 Err:520 $ 52,736 $ 21,094 $ 31,642 $ - ### $ - 1843
70 Orange Fullerton ESD 10/11-2 2013-Q1 $ - $ - ### $ 45,467 $ 34,100 $ (11,367) 2
71 Orange Fullerton ESD 11/12-2 Err:520 $ 120,007 $ 48,003 $ 72,004 $ - ### $ - 2613
72 Orange Fullerton ESD 10/11-3 2013-Q2 $ - $ - ### $ 50,186 $ 20,074 $ (30,112)
73 Orange Fullerton ESD 11/12-3 Err:520 $ 97,595 $ 39,038 $ 58,557 $ - ### $ - 3417
74 Orange Fullerton ESD 09/10-4 2012-Q3 $ - $ - ### $ 44,929 $ 33,697 $ (11,232) 2
75 Orange Fullerton ESD 10/11-4 Err:520 $ 38,058 $ 28,544 $ 9,514 $ - ### $ - 2 1222
76 Orange Fullerton ESD 11/12-4 Err:520 $ 99,014 $ 39,606 $ 59,408 $ - ### $ - 4186
77 Fullerton ESD Total $ 407,410 $ 176,285 $ 231,125 $ 140,582 $ 87,871 $ (52,711) $ 123,574
78 Orange Fullerton JUHSD 10/11-1 2012-Q4 $ - $ - ### $ 39,215 $ 27,451 $ (11,764)
79 Orange Fullerton JUHSD 11/12-1 Err:520 $ 51,730 $ 18,106 $ 33,624 $ - ### $ - 1844
80 Orange Fullerton JUHSD 10/11-2 2013-Q1 $ - $ - ### $ 90,110 $ 31,539 $ (58,571)
81 Orange Fullerton JUHSD 11/12-2 Err:520 $ 64,044 $ 22,415 $ 41,629 $ - ### $ - 2614
82 Orange Fullerton JUHSD 10/11-3 2013-Q2 $ - $ - ### $ 82,352 $ 28,823 $ (53,529)
83 Orange Fullerton JUHSD 11/12-3 Err:520 $ 72,719 $ 25,452 $ 47,267 $ - ### $ - 3418
84 Orange Fullerton JUHSD 09/10-4 2012-Q3 $ - $ - ### $ 31,345 $ 21,942 $ (9,403)
85 Orange Fullerton JUHSD 10/11-4 Err:520 $ 110,291 $ 38,602 $ 71,689 $ - ### $ - 1224
86 Orange Fullerton JUHSD 12/13-1 Err:520 $ 22,178 $ 22,178 $ - 4950
87 Orange Fullerton JUHSD 11/12-4 Err:520 $ 53,372 $ 18,680 $ 34,692 $ - ### $ - 4187
88 Fullerton JUHSD Total $ 374,334 $ 145,433 $ 228,901 $ 243,022 $ 109,755 $ (133,267) $ 12,166
89 Orange Garden Grove USD 10/11-1 2012-Q4 $ - $ - ### $ 96,420 $ 38,568 $ (57,852)
90 Orange Garden Grove USD 11/12-1 Err:520 $ 72,767 $ 29,107 $ 43,660 $ - ### $ - 1845
91 Orange Garden Grove USD 10/11-2 2013-Q1 $ - $ - ### $ 208,585 $ 83,434 $ (125,151)
92 Orange Garden Grove USD 11/12-2 Err:520 $ 201,100 $ 80,440 $ 120,660 $ - ### $ - 2615
93 Orange Garden Grove USD 10/11-3 2013-Q2 $ - $ - ### $ 237,931 $ 95,172 $ (142,759)
94 Orange Garden Grove USD 11/12-3 Err:520 $ 194,236 $ 77,694 $ 116,542 $ - ### $ - 3419
95 Orange Garden Grove USD 09/10-4 2012-Q3 $ - $ - ### $ 224,404 $ 89,762 $ (134,642)
96 Orange Garden Grove USD 10/11-4 Err:520 $ 189,540 $ 75,816 $ 113,724 $ - ### $ - 1225
97 Orange Garden Grove USD 12/13-1 Err:520 $ 56,334 $ 22,534 $ 33,800 4951
98 Orange Garden Grove USD 12/13-2 Err:520 $ 132,615 $ 53,046 $ 79,569 5746
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
99 Orange Garden Grove USD 12/13-3 Err:520 $ 148,451 $ 59,380 $ 89,071 6535
100 Orange Garden Grove USD 11/12-4 Err:520 $ 181,438 $ 72,575 $ 108,863 $ - ### $ - 4188
101 Garden Grove USD Total $ 1,176,481 $ 470,592 $ 705,889 $ 767,340 $ 306,936 $ (460,404) $ 10,188
102 Orange Grossmont UHSD 10/11-1 2012-Q4 $ - $ - ### $ 146,517 $ 58,607 $ (87,910)
103 Orange Grossmont Union UHSD 09/10-4 2012-Q3 $ - $ - ### $ 163,284 $ 65,314 $ (97,970)
104 Orange Grossmont UHSD 11/12-1 Err:520 $ 183,877 $ 73,551 $ 110,326 $ - ### $ - 1847
105 Orange Grossmont UHSD 10/11-2 2013-Q1 $ - $ - ### $ 150,330 $ 60,132 $ (90,198)
106 Orange Grossmont UHSD 11/12-2 Err:520 $ 171,260 $ 68,504 $ 102,756 $ - ### $ - 2618
107 Orange Grossmont UHSD 10/11-3 Err:520 $ 145,224 $ 58,090 $ 87,134 $ - ### $ - 801
108 Orange Grossmont UHSD 11/12-3 Err:520 $ 143,876 $ 57,550 $ 86,326 $ - ### $ - 3422
109 Orange Grossmont UHSD 10/11-4 Err:520 $ 138,069 $ 55,228 $ 82,841 $ - ### $ - 1226
110 Orange Grossmont UHSD 11/12-4 Err:520 $ 160,067 $ 64,027 $ 96,040 $ - ### $ - 4191
111 Grossmont UHSD Total $ 942,373 $ 376,950 $ 565,423 $ 460,131 $ 184,053 $ (276,078) $ 100,872
112 Orange Huntington Beach City SD 10/11-3 2013-Q2 $ - $ - ### $ 32,960 $ 25,000 $ (7,960) 2
113 Orange Huntington Beach City SD 11/12-3 Err:520 $ 38,257 $ 28,693 $ 9,564 $ - ### $ - 2 3423
114 Orange Huntington Beach City SD 09/10-4 2012-Q3 $ - $ - ### $ 31,464 $ 25,000 $ (6,464) 2
115 Orange Huntington Beach City SD 10/11-4 Err:520 $ 32,558 $ 25,000 $ 7,558 $ - ### $ - 2 1227
116 Orange Huntington Beach City SD 11/12-4 Err:520 $ 27,966 $ 25,000 $ 2,966 $ - ### $ - 2 4192
117 Huntington Beach City SD Total $ 98,781 $ 78,693 $ 20,088 $ 64,424 $ 50,000 $ (14,424) $ 64,269
118 Orange Huntington Beach Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 60,276 $ 24,110 $ (36,166)
119 Orange Huntington Beach Union HSD 11/12-1 Err:520 $ 65,873 $ 26,349 $ 39,524 $ - ### $ - 1849
120 Orange Huntington Beach Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 72,115 $ 28,846 $ (43,269)
121 Orange Huntington Beach Union HSD 11/12-2 Err:520 $ 58,405 $ 23,362 $ 35,043 $ - ### $ - 2620
122 Orange Huntington Beach Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 56,170 $ 22,468 $ (33,702)
123 Orange Huntington Beach Union HSD 11/12-3 Err:520 $ 42,612 $ 31,959 $ 10,653 $ - ### $ - 2 3424
124 Orange Huntington Beach Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 78,468 $ 31,387 $ (47,081)
125 Orange Huntington Beach Union HSD 10/11-4 Err:520 $ 73,385 $ 29,354 $ 44,031 $ - ### $ - 1228
126 Orange Huntington Beach Union HSD 12/13-1 Err:520 $ 48,226 $ 36,170 $ 12,056 4955
127 Orange Huntington Beach Union HSD 11/12-4 Err:520 $ 48,371 $ 36,278 $ 12,093 $ - ### $ - 2 4193
128 Huntington Beach Union HSD Total* $ 336,872 $ 183,472 $ 153,400 $ 267,029 $ 106,811 $ (160,218) $ 23,254
129 Orange Imperial COE 10/11-1 2012-Q4 $ - $ - ### $ 83,438 $ 33,375 $ (50,063)
130 Orange Imperial COE 11/12-1 Err:520 $ 71,784 $ 28,714 $ 43,070 $ - ### $ - 1850
131 Orange Imperial COE 10/11-2 2013-Q1 $ - $ - ### $ 89,320 $ 35,728 $ (53,592)
132 Orange Imperial COE 11/12-2 Err:520 $ 87,217 $ 34,887 $ 52,330 $ - ### $ - 2621
133 Orange Imperial COE 10/11-3 2013-Q2 $ - $ - ### $ 94,986 $ 37,994 $ (56,992)
134 Orange Imperial COE 11/12-3 Err:520 $ 61,368 $ 24,547 $ 36,821 $ - ### $ - 3425
135 Orange Imperial COE 09/10-4 2012-Q3 $ - $ - ### $ 84,700 $ 33,880 $ (50,820)
136 Orange Imperial COE 10/11-4 Err:520 $ 93,155 $ 37,262 $ 55,893 $ - ### $ - 1229
137 Orange Imperial COE 12/13-1 Err:520 $ 49,036 $ 36,777 $ 12,259 4956
138 Orange Imperial COE 12/13-2 Err:520 $ 65,889 $ 26,356 $ 39,533 5751
139 Orange Imperial COE 11/12-4 Err:520 $ 64,400 $ 25,760 $ 38,640 $ - ### $ - 4194
140 Imperial COE Total $ 492,849 $ 214,303 $ 278,546 $ 352,444 $ 140,977 $ (211,467) $ 2,836
141 Orange Irvine USD 10/11-1 2012-Q4 $ - $ - ### $ 63,076 $ 25,230 $ (37,846)
142 Orange Irvine USD 11/12-1 Err:520 $ 72,889 $ 29,156 $ 43,733 $ - ### $ - 1851
143 Orange Irvine USD 10/11-2 2013-Q1 $ - $ - ### $ 80,656 $ 32,262 $ (48,394)
144 Orange Irvine USD 11/12-2 Err:520 $ 75,540 $ 30,216 $ 45,324 $ - ### $ - 2622
145 Orange Irvine USD 10/11-3 Err:520 $ 92,395 $ 36,958 $ 55,437 $ - ### $ - 802
146 Orange Irvine USD 11/12-3 Err:520 $ 77,361 $ 30,944 $ 46,417 $ - ### $ - 3426
147 Orange Irvine USD 09/10-4 2012-Q3 $ - $ - ### $ 92,139 $ 36,856 $ (55,283)
148 Orange Irvine USD 10/11-4 Err:520 $ 85,961 $ 34,384 $ 51,577 $ - ### $ - 1230
149 Orange Irvine USD 11/12-4 Err:520 $ 70,214 $ 28,086 $ 42,128 $ - ### $ - 4195
150 Irvine USD Total $ 474,360 $ 189,744 $ 284,616 $ 235,871 $ 94,348 $ (141,523) $ 48,221
151 Orange La Habra City SD 11/12-2 Err:520 $ 33,116 $ 25,000 $ 8,116 $ - ### $ - 2 2625
152 Orange La Habra City SD 10/11-3 2013-Q2 $ - $ - ### $ 28,311 $ 25,000 $ (3,311) 2
153 3429 La Habra City SD 11/12-3 Err:520 $ 34,943 $ 26,207 $ 8,736 $ - ### $ - 2 3429
154 Orange La Habra City SD 09/10-4 2012-Q3 $ - $ - ### $ 36,638 $ 27,479 $ (9,159) 2
155 Orange La Habra City SD 11/12-4 Err:520 $ 38,647 $ 28,985 $ 9,662 $ - ### $ - 2 4198
156 La Habra City SD Total $ 106,706 $ 80,192 $ 26,514 $ 64,949 $ 52,479 $ (12,470) $ 67,722
157 Orange La Mesa-Spring Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 59,587 $ 59,587 $ -
158 Orange La Mesa-Spring Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 55,148 $ 55,148 $ -
159 Orange La Mesa - Spring Valley SD 11/12-3 Err:520 $ 54,894 $ 54,894 $ - $ - ### $ - 3430
160 Orange La Mesa-Spring Valley USD 11/12-2 Err:520 $ 62,036 $ 62,036 $ - $ - ### $ - 2626 2695 2654 2614 2636 2561 2600 2484 2490 2491 2498 2499
161 Orange La Mesa-Spring Valley USD 09/10-4 2012-Q3 $ - $ - ### $ 33,077 $ 33,077 $ - $ 2,386 $ 1,822 $ 3,203 $ 6,739 $ 4,654 $ 2,958 $ 1,980 $ 2,160 $ 1,705 $ 7,433 $ 2,182
162 Orange La Mesa-Spring Valley USD 11/12-4 Err:520 $ 41,328 $ 41,328 $ - $ - ### $ - 4199
163 La Mesa-Spring Valley USD Total* $ 158,258 $ 158,258 $ - $ 147,812 $ 147,812 $ - $ 158,258
164 Orange Los Alamitos USD 11/12-3 Err:520 $ 26,665 $ 25,000 $ 1,665 $ - ### $ - 2 3432
165 Los Alamitos USD Total $ 26,665 $ 25,000 $ 1,665 $ - $ - $ - $ 25,000
166 Orange Magnolia ESD 10/11-1 2012-Q4 $ - $ - ### $ 70,338 $ 28,135 $ (42,203)
167 Orange Magnolia ESD 11/12-1 Err:520 $ 71,809 $ 28,724 $ 43,085 $ - ### $ - 1855
168 Orange Magnolia ESD 10/11-2 2013-Q1 $ - $ - ### $ 79,761 $ 31,904 $ (47,857)
169 Orange Magnolia ESD 11/12-2 Err:520 $ 78,202 $ 31,281 $ 46,921 $ - ### $ - 2628
170 Orange Magnolia ESD 10/11-3 2013-Q2 $ - $ - ### $ 92,240 $ 36,896 $ (55,344)
171 Orange Magnolia ESD 11/12-3 Err:520 $ 75,279 $ 30,112 $ 45,167 $ - ### $ - 3433
172 Orange Magnolia ESD 09/10-4 2012-Q3 $ - $ - ### $ 79,184 $ 31,674 $ (47,510)
173 Orange Magnolia ESD 10/11-4 Err:520 $ 85,936 $ 34,374 $ 51,562 $ - ### $ - 1234
174 Orange Magnolia ESD 12/13-1 Err:520 $ 64,769 $ 25,908 $ 38,861 4965
175 Orange Magnolia ESD 12/13-2 Err:520 $ 74,623 $ 29,849 $ 44,774 5760
176 Orange Magnolia ESD 11/12-4 Err:520 $ 78,573 $ 31,429 $ 47,144 $ - ### $ - 4202
177 Magnolia ESD Total $ 529,191 $ 211,677 $ 317,514 $ 321,523 $ 128,609 $ (192,914) $ 18,763
178 Orange Newport - Mesa USD 10/11-1 2012-Q4 $ - $ - ### $ 227,792 $ 91,117 $ (136,675)
179 Orange Newport - Mesa USD 10/11-4 Err:520 $ 343,457 $ 137,383 $ 206,074 $ - ### $ - 1236
180 Orange Newport - Mesa USD 11/12-1 Err:520 $ 288,589 $ 115,436 $ 173,153 $ - ### $ - 1857
181 Orange Newport - Mesa USD 10/11-2 2013-Q1 $ - $ - ### $ 370,246 $ 148,098 $ (222,148)
182 Orange Newport - Mesa USD 11/12-2 Err:520 $ 351,822 $ 140,729 $ 211,093 $ - ### $ - 2630
183 Orange Newport - Mesa USD 10/11-3 Err:520 $ 312,418 $ 124,967 $ 187,451 $ - ### $ - 803
184 Orange Newport - Mesa USD 11/12-3 Err:520 $ 318,074 $ 127,230 $ 190,844 $ - ### $ - 3435
185 Orange Newport - Mesa USD 09/10-4 2012-Q3 $ - $ - ### $ 346,638 $ 138,655 $ (207,983)
186 Orange Newport - Mesa USD 11/12-4 Err:520 $ 323,698 $ 129,479 $ 194,219 $ - ### $ - 4204
187 Newport - Mesa USD Total* $ 1,938,058 $ 775,224 $ 1,162,834 $ 944,676 $ 377,870 $ (566,806) $ 208,418
188 Orange Ocean View ESD 10/11-1 2012-Q4 $ - $ - ### $ 39,906 $ 39,906 $ -
189 Orange Ocean View ESD 10/11-2 2013-Q1 $ - $ - ### $ 61,706 $ 61,706 $ -
190 Orange Ocean View ESD 11/12-2 Err:520 $ 116,019 $ 116,019 $ - $ - ### $ - 2631 2696 2699 2974 2973 2932 2910 2878 2703 2701 2668 2673 2677 2694
191 Orange Ocean View ESD 10/11-3 2013-Q2 $ - $ - ### $ 65,747 $ 65,747 $ - $ 4,317 $ 9,446 $ 3,352 $ 2,596 $ 6,638 $ 6,622 $ 5,386 $ 2,327 $ 7,247 $ 3,070 $ 8,943 $ 3,253 $ 6,414
192 Orange Ocean View ESD 11/12-3 Err:520 $ 124,691 $ 124,691 $ - $ - ### $ - 3436
193 Orange Ocean View ESD 09/10-4 2012-Q3 $ - $ - ### $ 53,306 $ 53,306 $ -
194 Orange Ocean View ESD 11/12-4 Err:520 $ 127,156 $ 127,156 $ - $ - ### $ - 4205
195 Ocean View ESD Total $ 367,866 $ 367,866 $ - $ 220,665 $ 220,665 $ - $ 367,866
196 Orange Oceanside Unified SD 10/11-1 2012-Q4 $ - $ - ### $ 109,274 $ 43,710 $ (65,564)
197 Orange Oceanside Unified SD 09/10-4 2012-Q3 $ - $ - ### $ 45,362 $ 34,022 $ (11,340)
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
198 Orange Oceanside Unified SD 10/11-4 Err:520 $ 91,644 $ 36,658 $ 54,986 $ - ### $ - 1240
199 Orange Oceanside Unified SD 11/12-1 Err:520 $ 139,043 $ 55,617 $ 83,426 $ - ### $ - 1858
200 Orange Oceanside Unified SD 10/11-2 2013-Q1 $ - $ - ### $ 111,478 $ 44,591 $ (66,887)
201 Orange Oceanside Unified SD 11/12-2 Err:520 $ 160,507 $ 64,203 $ 96,304 $ - ### $ - 2632
202 Orange Oceanside Unified SD 10/11-3 2013-Q2 $ - $ - ### $ 77,487 $ 30,995 $ (46,492)
203 Orange Oceanside Unified SD 11/12-3 Err:520 $ 160,016 $ 64,006 $ 96,010 $ - ### $ - 3437
204 Orange Oceanside Unified SD 11/12-4 Err:520 $ 171,903 $ 68,761 $ 103,142 $ - ### $ - 4206
205 Oceanside Unified SD Total* $ 723,113 $ 289,245 $ 433,868 $ 343,601 $ 153,318 $ (190,283) $ 98,962
206 Orange Orange CDE - Sp Ed 10/11-2 2013-Q1 $ - $ - ### $ 29,194 $ 25,000 $ (4,194) 2
207 Orange Orange CDE - Sp Ed 10/11-3 2013-Q2 $ - $ - ### $ 25,935 $ 25,000 $ (935) 2
208 Orange Orange CDE - Sp Ed 11/12-3 Err:520 $ 91,151 $ 36,460 $ 54,691 $ - ### $ - 3438
209 Orange Orange CDE - Sp Ed 11/12-4 Err:520 $ 69,719 $ 27,888 $ 41,831 $ - ### $ - 4207
210 Orange CDE - Sp Ed Total $ 160,870 $ 64,348 $ 96,522 $ 55,129 $ 50,000 $ (5,129) $ 59,219
211 Orange Orange USD 10/11-1 2012-Q4 $ - $ - ### $ 55,299 $ 55,299 $ -
212 Orange Orange USD 10/11-2 2013-Q1 $ - $ - ### $ 103,375 $ 103,375 $ -
213 Orange Orange USD 10/11-3 2013-Q2 $ - $ - ### $ 130,247 $ 130,247 $ -
214 Orange Orange USD 09/10-4 2012-Q3 $ - $ - ### $ 135,872 $ 135,872 $ -
215 Orange Orange USD 11/12-4 Err:520 $ 104,437 $ 104,437 $ - $ - ### $ - 4209
216 Orange USD Total $ 104,437 $ 104,437 $ - $ 424,793 $ 424,793 $ - $ 104,437
217 Orange Placentia-Yorba Linda USD 10/11-1 2012-Q4 $ - $ - ### $ 148,561 $ 59,424 $ (89,137)
218 Orange Placentia-Yorba Linda USD 10/11-4 Err:520 $ 194,154 $ 77,662 $ 116,492 $ - ### $ - 1241
219 Orange Placentia-Yorba Linda USD 11/12-1 Err:520 $ 155,844 $ 62,338 $ 93,506 $ - ### $ - 1861
220 Orange Placentia-Yorba Linda USD 10/11-2 2013-Q1 $ - $ - ### $ 232,944 $ 93,178 $ (139,766)
221 Orange Placentia-Yorba Linda USD 11/12-2 Err:520 $ 190,729 $ 76,292 $ 114,437 $ - ### $ - 2635
222 Orange Placentia-Yorba Linda USD 10/11-3 2013-Q2 $ - $ - ### $ 232,014 $ 92,806 $ (139,208)
223 Orange Placentia-Yorba Linda USD 11/12-3 Err:520 $ 209,478 $ 83,791 $ 125,687 $ - ### $ - 3440
224 Orange Placentia-Yorba Linda USD 09/10-4 2012-Q3 $ - $ - ### $ 260,238 $ 104,095 $ (156,143)
225 Orange Placentia-Yorba Linda USD 12/13-1 Err:520 $ 81,522 $ 32,609 $ 48,913 4973
226 Orange Placentia-Yorba Linda USD 12/13-2 Err:520 $ 151,320 $ 60,528 $ 90,792 5769
227 Orange Placentia-Yorba Linda USD 12/13-3 Err:520 $ 136,862 $ 54,745 $ 82,117 6557
228 Orange Placentia-Yorba Linda USD 12/13-4 Err:520 $ 127,265 $ 50,906 $ 76,359
229 Orange Placentia-Yorba Linda USD 11/12-4 Err:520 $ 132,711 $ 53,084 $ 79,627 $ - ### $ - 4210
230 Placentia-Yorba Linda USD Total* $ 1,379,885 $ 551,955 $ 827,930 $ 873,757 $ 349,503 $ (524,254) $ 27,701
231 Orange San Diego City College 11/12-1 Err:520 $ 35,536 $ 24,875 $ 10,661 $ - ### $ - 1862
232 Orange San Diego City College 11/12-2 Err:520 $ 26,087 $ 18,261 $ 7,826 $ - ### $ - 2636
233 Orange San Diego City College 11/12-3 Err:520 $ 33,336 $ 23,335 $ 10,001 $ - ### $ - 3441
234 Orange San Diego City College 11/12-4 Err:520 $ 26,738 $ 18,717 $ 8,021 $ - ### $ - 4211
235 San Diego City College Total $ 121,697 $ 85,188 $ 36,509 $ - $ - $ - $ 85,188
236 Orange San Diego CSS 10/11-1 2012-Q4 $ - $ - ### $ 161,774 $ 64,710 $ (97,064)
237 Orange San Diego CSS 11/12-1 Err:520 $ 124,761 $ 49,904 $ 74,857 $ - ### $ - 1863
238 Orange San Diego CSS 10/11-2 2013-Q1 $ - $ - ### $ 161,312 $ 64,525 $ (96,787)
239 Orange San Diego CSS 11/12-2 Err:520 $ 101,527 $ 40,611 $ 60,916 $ - ### $ - 2637
240 Orange San Diego CSS 10/11-3 Err:520 $ 127,654 $ 51,062 $ 76,592 $ - ### $ - 804
241 Orange San Diego CSS 11/12-3 Err:520 $ 92,578 $ 37,031 $ 55,547 $ - ### $ - 3442
242 Orange San Diego CSS 09/10-4 2012-Q3 $ - $ - ### $ 134,089 $ 53,636 $ (80,453)
243 Orange San Diego CSS 10/11-4 Err:520 $ 170,848 $ 68,339 $ 102,509 $ - ### $ - 1242
244 Orange San Diego CSS 11/12-4 Err:520 $ 85,164 $ 34,066 $ 51,098 $ - ### $ - 4212
245 San Diego CSS Total $ 702,532 $ 281,013 $ 421,519 $ 457,175 $ 182,871 $ (274,304) $ 6,709
246 Orange San Diego USD 10/11-1 2012-Q4 $ - $ - ### $ 597,306 $ 238,922 $ (358,384)
247 Orange San Diego USD 11/12-1 Err:520 $ 658,570 $ 263,428 $ 395,142 $ - ### $ - 1864
248 Orange San Diego USD 10/11-2 2013-Q1 $ - $ - ### $ 741,846 $ 296,738 $ (445,108)
249 Orange San Diego USD 11/12-2 Err:520 $ 643,233 $ 257,293 $ 385,940 $ - ### $ - 2638
250 Orange San Diego USD 10/11-3 2013-Q2 $ - $ - ### $ 711,944 $ 284,778 $ (427,166)
251 Orange San Diego USD 11/12-3 Err:520 $ 646,530 $ 258,039 $ 388,491 $ - ### $ - 3443
252 Orange San Diego USD 09/10-4 2012-Q3 $ - $ - ### $ 624,873 $ 249,949 $ (374,924)
253 Orange San Diego USD 10/11-4 Err:520 $ 696,155 $ 278,462 $ 417,693 $ - ### $ - 1243
254 Orange San Diego USD 12/13-1 Err:520 $ 371,893 $ 148,757 $ 223,136 4976
255 Orange San Diego USD 12/13-2 Err:520 $ 423,644 $ 169,458 $ 254,186 5773
256 Orange San Diego USD 11/12-4 Err:520 $ 592,647 $ 237,059 $ 355,588 $ - ### $ - 4213
257 San Diego USD Total $ 4,032,672 $ 1,612,496 $ 2,420,176 $ 2,675,969 $ 1,070,387 $ (1,605,582) $ 6,914
258 Orange San Marcos USD 10/11-1 2012-Q4 $ - $ - ### $ 103,198 $ 41,279 $ (61,919)
259 Orange San Marcos USD 11/12-1 Err:520 $ 152,159 $ 60,864 $ 91,295 $ - ### $ - 1865
260 Orange San Marcos USD 10/11-2 2013-Q1 $ - $ - ### $ 130,106 $ 52,042 $ (78,064)
261 Orange San Marcos USD 11/12-2 Err:520 $ 154,392 $ 61,757 $ 92,635 $ - ### $ - 2639
262 Orange San Marcos USD 10/11-3 2013-Q2 $ - $ - ### $ 124,824 $ 49,930 $ (74,894)
263 Orange San Marcos USD 11/12-3 Err:520 $ 160,093 $ 64,037 $ 96,056 $ - ### $ - 3444
264 Orange San Marcos USD 09/10-4 2012-Q3 $ - $ - ### $ 86,932 $ 34,773 $ (52,159)
265 Orange San Marcos USD 10/11-4 Err:520 $ 82,079 $ 32,832 $ 49,247 $ - ### $ - 1244
266 Orange San Marcos USD 11/12-4 Err:520 $ 135,212 $ 54,085 $ 81,127 $ - ### $ - 4214
267 San Marcos USD Total $ 683,935 $ 273,575 $ 410,360 $ 445,060 $ 178,024 $ (267,036) $ 6,539
268 Orange San Ysidro ESD 10/11-1 2012-Q4 $ - $ - ### $ 38,850 $ 29,138 $ (9,712) 2
269 Orange San Ysidro ESD 11/12-1 Err:520 $ 38,372 $ 28,779 $ 9,593 $ - ### $ - 2 1866
270 Orange San Ysidro ESD 11/12-2 Err:520 $ 28,159 $ 25,000 $ 3,159 $ - ### $ - 2 2640
271 Orange San Ysidro ESD 10/11-4 2013-Q3 $ - $ - ### $ 42,983 $ 32,237 $ (10,746) 2
272 Orange San Ysidro ESD 11/12-4 Err:520 $ 27,503 $ 25,000 $ 2,503 $ - ### $ - 2 4215
273 San Ysidro ESD Total $ 94,034 $ 78,779 $ 15,255 $ 81,833 $ 61,375 $ (20,458) $ 58,321
274 Orange Santa Ana USD 10/11-1 2012-Q4 $ - $ - ### $ 283,912 $ 113,565 $ (170,347)
275 Orange Santa Ana USD 11/12-1 Err:520 $ 258,073 $ 103,229 $ 154,844 $ - ### $ - 1867
276 Orange Santa Ana USD 10/11-2 2013-Q1 $ - $ - ### $ 485,358 $ 194,143 $ (291,215)
277 Orange Santa Ana USD 11/12-2 Err:520 $ 424,461 $ 169,784 $ 254,677 $ - ### $ - 2641
278 Orange Santa Ana USD 10/11-3 2013-Q2 $ - $ - ### $ 439,632 $ 175,853 $ (263,779)
279 Orange Santa Ana USD 11/12-3 Err:520 $ 425,448 $ 170,179 $ 255,269 $ - ### $ - 3446
280 Orange Santa Ana USD 09/10-4 2012-Q3 $ - $ - ### $ 254,032 $ 101,613 $ (152,419)
281 Orange Santa Ana USD 10/11-4 Err:520 $ 457,416 $ 182,966 $ 274,450 $ - ### $ - 1245
282 Orange Santa Ana USD 12/13-1 Err:520 $ 244,130 $ 97,652 $ 146,478 4979
283 Orange Santa Ana USD 11/12-4 Err:520 $ 435,024 $ 174,010 $ 261,014 $ - ### $ - 4216
284 Santa Ana USD Total $ 2,244,552 $ 897,820 $ 1,346,732 $ 1,462,934 $ 585,174 $ (877,760) $ 20,060
285 Orange Santee ESD 10/11-1 2012-Q4 $ - $ - ### $ 33,340 $ 25,005 $ (8,335) 2
286 Orange Santee ESD 11/12-1 Err:520 $ 30,422 $ 25,000 $ 5,422 $ - ### $ - 2 1868, 1922 1922
287 Orange Santee ESD 10/11-2 Err:520 $ 69,246 $ 27,698 $ 41,548 $ - ### $ - 605 $ 2,184
288 Orange Santee ESD 11/12-2 Err:520 $ 30,313 $ 25,000 $ 5,313 $ - ### $ - 2 2642
289 Orange Santee ESD 10/11-3 Err:520 $ 57,703 $ 23,081 $ 34,622 $ - ### $ - 805
290 Orange Santee ESD 11/12-3 Err:520 $ 28,900 $ 25,000 $ 3,900 $ - ### $ - 2 3447
291 Orange Santee ESD 10/11-4 Err:520 $ 78,589 $ 31,436 $ 47,153 $ - ### $ - 1246
292 Santee ESD Total $ 295,173 $ 157,215 $ 137,958 $ 33,340 $ 25,005 $ (8,335) $ 148,880
293 Orange Savanna ESD 10/11-2 2013-Q1 $ - $ - ### $ 29,229 $ 29,229 $ -
294 Orange Savanna ESD 10/11-3 2013-Q2 $ - $ - ### $ 32,810 $ 32,810 $ -
295 Orange Savanna ESD 09/10-4 2012-Q3 $ - $ - ### $ 44,508 $ 44,508 $ -
296 Orange Savanna ESD 11/12-4 Err:520 $ - $ - $ - ### $ -
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
297 Savanna ESD Total $ - $ - $ - $ 106,547 $ 106,547 $ - $ -
298 Orange Sweetwater UHSD 10/11-1 2012-Q4 $ - $ - ### $ 267,512 $ 107,005 $ (160,507)
299 Orange Sweetwater UHSD 11/12-1 Err:520 $ 166,809 $ 66,724 $ 100,085 $ - ### $ - 1869
300 Orange Sweetwater UHSD 10/11-2 Err:520 $ 193,796 $ 77,518 $ 116,278 $ - ### $ - 606
301 Orange Sweetwater UHSD 11/12-2 Err:520 $ 152,109 $ 60,844 $ 91,265 $ - ### $ - 2643
302 Orange Sweetwater UHSD 09/10-3 2012-Q2 $ - $ - ### $ 179,091 $ 71,636 $ (107,455)
303 Orange Sweetwater UHSD 10/11-3 Err:520 $ 238,567 $ 95,427 $ 143,140 $ - ### $ - 806
304 Orange Sweetwater UHSD 11/12-3 Err:520 $ 144,340 $ 57,736 $ 86,604 $ - ### $ - 3448
305 Orange Sweetwater UHSD 09/10-4 2012-Q3 $ - $ - ### $ 381,037 $ 152,415 $ (228,622)
306 Orange Sweetwater UHSD 10/11-4 Err:520 $ 182,788 $ 73,115 $ 109,673 $ - ### $ - 1247
307 Orange Sweetwater UHSD 12/13-1 Err:520 $ 95,097 $ 38,039 $ 57,058 4982
308 Orange Sweetwater UHSD 11/12-4 Err:520 $ 141,189 $ 56,476 $ 84,713 $ - ### $ - 4218
309 Sweetwater UHSD Total $ 1,314,695 $ 525,879 $ 788,816 $ 827,640 $ 331,056 $ (496,584) $ 29,295
310 Orange Tustin USD 10/11-2 2013-Q1 $ - $ - ### $ 40,782 $ 40,782 $ -
311 Orange Tustin USD 10/11-3 2013-Q2 $ - $ - ### $ 40,861 $ 40,861 $ -
312 Orange Tustin USD 09/10-4 2012-Q3 $ - $ - ### $ 41,373 $ 41,373 $ -
313 Orange Tustin USD 11/12-4 Err:520 $ - $ - $ - ### $ -
314 Tustin USD Total $ - $ - $ - $ 123,016 $ 123,016 $ - $ -
315 Orange Vista USD 10/11-1 Err:520 $ 140,359 $ - ### $ - 502
316 Orange Vista USD 11/12-1 Err:520 $ 174,261 $ 69,704 $ 104,557 $ - ### $ - 1870
317 Orange Vista USD 10/11-2 2013-Q1 $ - $ - ### $ 225,538 $ 90,215 $ (135,323)
318 Orange Vista USD 11/12-2 Err:520 $ 292,060 $ 116,824 $ 175,236 $ - ### $ - 2644
319 Orange Vista USD 09/10-3 2012-Q2 $ - $ - ### $ 39,890 $ 29,918 $ (9,972) 2
320 Orange Vista USD 10/11-3 2013-Q2 $ - $ - ### $ 170,062 $ 68,025 $ (102,037)
321 Orange Vista USD 11/12-3 Err:520 $ 220,923 $ 88,369 $ 132,554 $ - ### $ - 3449
322 Orange Vista USD 09/10-4 2012-Q3 $ - $ - ### $ 29,895 $ 25,000 $ (4,895) 2
323 Orange Vista USD 10/11-4 Err:520 $ 159,974 $ 63,990 $ 95,984 $ - ### $ - 1248
324 Orange Vista USD 11/12-4 Err:520 $ 182,548 $ 73,019 $ 109,529 $ - ### $ - 4219
325 Vista USD Total $ 1,170,125 $ 411,906 $ 617,860 $ 465,385 $ 213,158 $ (252,227) $ 159,679
326 Orange Westminster SD 10/11-1 2012-Q4 $ - $ - ### $ 48,893 $ 36,670 $ (12,223) 2
327 Orange Westminster SD 11/12-1 Err:520 $ 44,080 $ 33,060 $ 11,020 $ - ### $ - 2 1871
328 Orange Westminster SD 10/11-2 2013-Q1 $ - $ - ### $ 65,654 $ 26,262 $ (39,392)
329 Orange Westminster SD 11/12-2 Err:520 $ 68,165 $ 27,266 $ 40,899 $ - ### $ - 2645
330 Orange Westminster SD 10/11-3 Err:520 $ 85,042 $ 34,017 $ 51,025 $ - ### $ - 807
331 Orange Westminster SD 11/12-3 Err:520 $ 71,670 $ 28,668 $ 43,002 $ - ### $ - 3450
332 Orange Westminster SD 09/10-4 2012-Q3 $ - $ - ### $ 60,706 $ 24,282 $ (36,424)
333 Orange Westminster SD 10/11-4 Err:520 $ 82,126 $ 32,850 $ 49,276 $ - ### $ - 1249
334 Orange Westminster SD 11/12-4 Err:520 $ 59,364 $ 23,746 $ 35,618 $ - ### $ - 4220
335 Westminster SD Total $ 410,447 $ 179,607 $ 230,840 $ 175,253 $ 87,214 $ (88,039) $ 91,568
336 Grand Total Orange LEC Err:502 Err:502 Err:502 $ 15,482,842 $ 7,811,739 $ (7,671,103) Err:502
337
338
339 Column A County - Reporting LEC/LGA
340 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
341 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
342 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
343 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
344 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
345 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
346 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
347 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
348 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
349 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
350 The last subtotal amount is the final amount due to/from the LEC/LGA
351 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
352

353 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
354 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
355 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
356

357 Released Claiming Unit Invoice on placeholder to be paid 100%


358

359 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
360 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
361

362 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
363 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
364 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
365 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
366

367 Claiming units no longer participating (5% reduction)


368
369 12/13 claims
370 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Pasadena LGA Pasadena USD 10/11-1 2012-Q4 $ - $ - ### $ 120,511 $ 48,204 $ (72,307)
3 Pasadena LGA Pasadena USD 11/12-1 Err:520 $ 138,145 $ 55,258 $ 82,887 $ - ### $ - 1872
4 Pasadena LGA Pasadena USD 10/11-2 Err:520 $ 230,978 $ 92,391 $ 138,587 $ - ### $ - 607
5 Pasadena LGA Pasadena USD 11/12-2 Err:520 $ 203,798 $ 81,519 $ 122,279 $ - ### $ - 2646
6 Pasadena LGA Pasadena USD 10/11-3 Err:520 $ 220,538 $ 88,215 $ 132,323 $ - ### $ - 808
7 Pasadena LGA Pasadena USD 11/12-3 Err:520 $ 174,096 $ 69,638 $ 104,458 $ - ### $ - 3451
8 Pasadena LGA Pasadena USD 09/10-4 2012-Q3 $ - $ - ### $ 268,460 $ 107,384 $ (161,076)
9 Pasadena LGA Pasadena USD 10/11-4 Err:520 $ 258,533 $ 103,413 $ 155,120 $ - ### $ - 1250
10 Pasadena LGA Pasadena USD 11/12-4 Err:520 $ 244,664 $ 97,866 $ 146,798 $ - ### $ - 4221
11 Pasadena USD Total $ 1,470,752 $ 588,300 $ 882,452 $ 388,971 $ 155,588 $ (233,383) $ 354,917
12 Grand Total Pasadena LGA $ 1,470,752 $ 588,300 $ 882,452 $ 388,971 $ 155,588 $ (233,383) $ 354,917
13
14
15 Column A County - Reporting LEC/LGA
16 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
17 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
18 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
19 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
20 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
21 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
22 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
23 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
24 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
25 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
26 The last subtotal amount is the final amount due to/from the LEC/LGA
27 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
28

29 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
30 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
31 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
32

33 Released Claiming Unit Invoice on placeholder to be paid 100%


34

35 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
36 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
37

38 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
39 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
40 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
41 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
42

43 Claiming units no longer participating (5% reduction)


44
45 12/13 claims
46 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Riverside LGA Beaumont Union SD 10/11-1 2012-Q4 $ - $ - ### $ 60,188 $ 24,075 $ (36,113)
3 Riverside LGA Beaumont Union SD 11/12-1 Err:520 $ 34,158 $ 25,619 $ 8,539 $ - ### $ - 1 1874
4 Riverside LGA Beaumont Union SD 10/11-2 2013-Q1 $ - $ - ### $ 35,556 $ 26,667 $ (8,889)
5 Riverside LGA Beaumont Union SD 11/12-2 Err:520 $ 56,733 $ 22,693 $ 34,040 $ - ### $ - 2648
6 Riverside LGA Beaumont Union SD 10/11-3 Err:520 $ 60,077 $ 24,031 $ 36,046 $ - ### $ - 809
7 Riverside LGA Beaumont Union SD 11/12-3 Err:520 $ 67,954 $ 27,182 $ 40,772 $ - ### $ - 3453
8 Riverside LGA Beaumont Union SD 10/11-4 Err:520 $ 52,827 $ 21,131 $ 31,696 $ - ### $ - 1252
9 Beaumont Union SD Total $ 271,749 $ 120,656 $ 151,093 $ 95,744 $ 50,742 $ (45,002) $ 75,654
10 Riverside LGA Coachella Valley USD 11/12-1 Err:520 $ 30,589 $ 25,000 $ 5,589 $ - ### $ - 2 1875
11 Riverside LGA Coachella Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 25,614 $ 25,000 $ (614) 2
12 Riverside LGA Coachella Valley USD 11/12-2 Err:520 $ 25,477 $ 25,000 $ 477 $ - ### $ - 2 2649
13 Riverside LGA Coachella Valley USD 10/11-3 2013-Q2 $ - $ - ### $ 28,354 $ 25,000 $ (3,354) 2
14 Riverside LGA Coachella Valley USD 11/12-3 Err:520 $ 46,077 $ 34,558 $ 11,519 $ - ### $ - 2 3454
15 Riverside LGA Coachella Valley USD 11/12-4 Err:520 $ 30,690 $ 25,000 $ 5,690 $ - ### $ - 2 4224
16 Coachella Valley USD Total $ 132,833 $ 109,558 $ 23,275 $ 53,968 $ 50,000 $ (3,968) $ 105,590
17 Riverside LGA Corona - Norco USD 10/11-1 2012-Q4 $ - $ - ### $ 546,367 $ 218,547 $ (327,820)
18 Riverside LGA Corona - Norco USD 11/12-1 Err:520 $ 573,829 $ 229,532 $ 344,297 $ - ### $ - 1876
19 Riverside LGA Corona - Norco USD 10/11-2 2013-Q1 $ - $ - ### $ 379,329 $ 151,732 $ (227,597)
20 Riverside LGA Corona - Norco USD 11/12-2 Err:520 $ 551,555 $ 220,622 $ 330,933 $ - ### $ - 2650
21 Riverside LGA Corona - Norco USD 10/11-3 2013-Q2 $ - $ - ### $ 682,882 $ 273,153 $ (409,729)
22 Riverside LGA Corona - Norco USD 11/12-3 Err:520 $ 938,991 $ 375,596 $ 563,395 $ - ### $ - 3455
23 Riverside LGA Corona - Norco USD 10/11-4 Err:520 $ 483,561 $ 193,424 $ 290,137 $ - ### $ - 1253
24 Riverside LGA Corona - Norco USD 11/12-4 Err:520 $ 658,416 $ 263,366 $ 395,050 $ - ### $ - 4225
25 Corona - Norco USD Total $ 3,206,352 $ 1,282,540 $ 1,923,812 $ 1,608,578 $ 643,432 $ (965,146) $ 317,394
26 Riverside LGA Desert Sands USD 10/11-1 2012-Q4 $ - $ - ### $ 92,598 $ 37,039 $ (55,559)
27 Riverside LGA Desert Sands USD 11/12-1 Err:520 $ 76,503 $ 30,601 $ 45,902 $ - ### $ - 1877
28 Riverside LGA Desert Sands USD 10/11-2 2013-Q1 $ - $ - ### $ 155,857 $ 62,343 $ (93,514)
29 Riverside LGA Desert Sands USD 11/12-2 Err:520 $ 183,177 $ 73,271 $ 109,906 $ - ### $ - 2651
30 Riverside LGA Desert Sands USD 10/11-3 2013-Q2 $ - $ - ### $ 166,465 $ 66,586 $ (99,879)
31 Riverside LGA Desert Sands USD 11/12-3 Err:520 $ 151,026 $ 60,410 $ 90,616 $ - ### $ - 3456
32 Riverside LGA Desert Sands USD 09/10-4 2012-Q3 $ - $ - ### $ 113,057 $ 45,223 $ (67,834)
33 Riverside LGA Desert Sands USD 10/11-4 Err:520 $ 138,879 $ 55,552 $ 83,327 $ - ### $ - 1254
34 Riverside LGA Desert Sands USD 12/13-1 Err:520 $ 68,406 $ 27,362 $ 41,044 4991
35 Riverside LGA Desert Sands USD 12/13-2 Err:520 $ 138,509 $ 55,404 $ 83,105
36 Riverside LGA Desert Sands USD 11/12-4 Err:520 $ 159,980 $ 63,992 $ 95,988 $ - ### $ - 4226
37 Desert Sands USD Total $ 916,480 $ 366,592 $ 549,888 $ 527,977 $ 211,191 $ (316,786) $ 49,806
38 Riverside LGA Hemet USD 10/11-1 2012-Q4 $ - $ - ### $ 279,759 $ 111,904 $ (167,855)
39 Riverside LGA Hemet USD 11/12-1 Err:520 $ 211,994 $ 84,798 $ 127,196 $ - ### $ - 1878
40 Riverside LGA Hemet USD 10/11-2 2013-Q1 $ - $ - ### $ 272,231 $ 108,892 $ (163,339)
41 Riverside LGA Hemet USD 11/12-2 Err:520 $ 255,710 $ 102,284 $ 153,426 $ - ### $ - 2652
42 Riverside LGA Hemet USD 10/11-3 2013-Q2 $ - $ - ### $ 473,534 $ 189,414 $ (284,120)
43 Riverside LGA Hemet USD 11/12-3 Err:520 $ 439,359 $ 175,744 $ 263,615 $ - ### $ - 3457
44 Riverside LGA Hemet USD 09/10-4 2012-Q3 $ - $ - ### $ 453,494 $ 181,398 $ (272,096)
45 Riverside LGA Hemet USD 10/11-4 Err:520 $ 352,559 $ 141,024 $ 211,535 $ - ### $ - 1255
46 Riverside LGA Hemet USD 12/13-1 Err:520 $ 195,448 $ 78,179 $ 117,269 4992
47 Riverside LGA Hemet USD 12/13-2 Err:520 $ 197,579 $ 79,032 $ 118,547
48 Riverside LGA Hemet USD 12/13-3 Err:520 $ 370,684 $ 148,274 $ 222,410
49 Riverside LGA Hemet USD 11/12-4 Err:520 $ 330,131 $ 132,052 $ 198,079 $ - ### $ - 4227
50 Hemet USD Total $ 2,353,464 $ 941,387 $ 1,412,077 $ 1,479,018 $ 591,608 $ (887,410) $ 53,977
51 Riverside LGA Jurupa USD 10/11-1 2012-Q4 $ - $ - ### $ 154,029 $ 61,612 $ (92,417)
52 Riverside LGA Jurupa USD 11/12-1 Err:520 $ 191,050 $ 76,420 $ 114,630 $ - ### $ - 1879
53 Riverside LGA Jurupa USD 10/11-2 2013-Q1 $ - $ - ### $ 96,195 $ 38,478 $ (57,717)
54 Riverside LGA Jurupa USD 11/12-2 Err:520 $ 140,914 $ 56,366 $ 84,548 $ - ### $ - 2653
55 Riverside LGA Jurupa USD 10/11-3 Err:520 $ 192,861 $ 77,144 $ 115,717 $ - ### $ - 810
56 Riverside LGA Jurupa USD 11/12-3 Err:520 $ 225,145 $ 90,058 $ 135,087 $ - ### $ - 3458
57 Riverside LGA Jurupa USD 09/10-4 2012-Q3 $ - $ - ### $ 166,020 $ 66,408 $ (99,612)
58 Riverside LGA Jurupa USD 10/11-4 Err:520 $ 117,097 $ 46,839 $ 70,258 $ - ### $ - 1256
59 Riverside LGA Jurupa USD 11/12-4 Err:520 $ 152,049 $ 60,820 $ 91,229 $ - ### $ - 4228
60 Jurupa USD Total $ 1,019,116 $ 407,647 $ 611,469 $ 416,244 $ 166,498 $ (249,746) $ 157,901
61 Riverside LGA Menifee Union SD 10/11-1 2012-Q4 $ - $ - ### $ 27,790 $ 19,453 $ (8,337)
62 Riverside LGA Menifee Union SD 11/12-1 Err:520 $ 46,714 $ 32,700 $ 14,014 $ - ### $ - 1880
63 Riverside LGA Menifee Union SD 10/11-2 2013-Q1 $ - $ - ### $ 30,841 $ 21,589 $ (9,252)
64 Riverside LGA Menifee Union SD 11/12-2 Err:520 $ 36,432 $ 25,502 $ 10,930 $ - ### $ - 2654
65 Riverside LGA Menifee Union SD 10/11-3 2013-Q2 $ - $ - ### $ 33,111 $ 23,178 $ (9,933)
66 Riverside LGA Menifee Union SD 11/12-3 Err:520 $ 44,971 $ 31,480 $ 13,491 $ - ### $ - 3459
67 Riverside LGA Menifee Union SD 09/10-4 2012-Q3 $ - $ - ### $ 34,749 $ 24,324 $ (10,425)
68 Riverside LGA Menifee Union SD 10/11-4 Err:520 $ 33,676 $ 23,573 $ 10,103 $ - ### $ - 1257
69 Riverside LGA Menifee Union SD 11/12-4 Err:520 $ 42,454 $ 29,718 $ 12,736 $ - ### $ - 4229
70 Menifee Union SD Total $ 204,247 $ 142,973 $ 61,274 $ 126,491 $ 88,544 $ (37,947) $ 105,026
71 Riverside LGA Moreno Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 44,586 $ 33,440 $ (11,146)
72 Riverside LGA Moreno Valley USD 11/12-1 Err:520 $ 100,693 $ 40,277 $ 60,416 $ - ### $ - 1881
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
73 Riverside LGA Moreno Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 109,591 $ 43,836 $ (65,755)
74 Riverside LGA Moreno Valley USD 11/12-2 Err:520 $ 179,181 $ 71,672 $ 107,509 $ - ### $ - 2655
75 Riverside LGA Moreno Valley USD 09/10-3 2012-Q2 $ - $ - ### $ 49,400 $ 37,050 $ (12,350)
76 Riverside LGA Moreno Valley USD 10/11-3 2013-Q2 $ - $ - ### $ 71,664 $ 28,666 $ (42,998)
77 Riverside LGA Moreno Valley USD 11/12-3 Err:520 $ 223,214 $ 89,286 $ 133,928 $ - ### $ - 3460
78 Riverside LGA Moreno Valley USD 10/11-4 2013-Q3 $ - $ - ### $ 34,435 $ 25,826 $ (8,609)
79 Riverside LGA Moreno Valley USD 11/12-4 Err:520 $ 139,610 $ 55,844 $ 83,766 $ - ### $ - 4230
80 Moreno Valley USD Total $ 642,698 $ 257,079 $ 385,619 $ 309,676 $ 168,818 $ (140,858) $ 116,221
81 Riverside LGA Murrieta Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 116,295 $ 46,518 $ (69,777)
82 Riverside LGA Murrieta Valley USD 11/12-1 Err:520 $ 295,366 $ 118,146 $ 177,220 $ - ### $ - 1882
83 Riverside LGA Murrieta Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 87,813 $ 35,125 $ (52,688)
84 Riverside LGA Murrieta Valley USD 11/12-2 Err:520 $ 165,186 $ 66,074 $ 99,112 $ - ### $ - 2656
85 Riverside LGA Murrieta Valley USD 10/11-3 Err:520 $ 145,930 $ 58,372 $ 87,558 $ - ### $ - 811
86 Riverside LGA Murrieta Valley USD 11/12-3 Err:520 $ 245,275 $ 98,110 $ 147,165 $ - ### $ - 3461
87 Riverside LGA Murrieta Valley USD 09/10-4 2012-Q3 $ - $ - ### $ 106,408 $ 42,563 $ (63,845)
88 Riverside LGA Murrieta Valley USD 10/11-4 Err:520 $ 115,240 $ 46,096 $ 69,144 $ - ### $ - 1258
89 Riverside LGA Murrieta Valley USD 11/12-4 Err:520 $ 209,575 $ 83,830 $ 125,745 $ - ### $ - 4231
90 Murrieta Valley USD Total $ 1,176,572 $ 470,628 $ 705,944 $ 310,516 $ 124,206 $ (186,310) $ 284,318
91 Riverside LGA NuView Union SD 11/12-1 Err:520 $ 33,385 $ 25,039 $ 8,346 $ - ### $ - 2 1883
92 Riverside LGA NuView Union SD 10/11-2 2013-Q1 $ - $ - ### $ 30,471 $ 25,000 $ (5,471) 2
93 Riverside LGA NuView Union SD 11/12-2 Err:520 $ 27,801 $ 25,000 $ 2,801 $ - ### $ - 2 2657
94 Riverside LGA NuView Union SD 10/11-3 2013-Q2 $ - $ - ### $ 33,399 $ 25,049 $ (8,350) 2
95 Riverside LGA NuView Union SD 11/12-3 Err:520 $ 25,895 $ 25,000 $ 895 $ - ### $ - 2 3462
96 Riverside LGA NuView Union SD 10/11-4 Err:520 $ 31,890 $ 25,000 $ 6,890 $ - ### $ - 2 1259
97 Riverside LGA NuView Union SD 11/12-4 Err:520 $ 25,636 $ 25,000 $ 636 $ - ### $ - 2 4232
98 NuView Union SD Total $ 144,607 $ 125,039 $ 19,568 $ 63,870 $ 50,049 $ (13,821) $ 111,218
99 Riverside LGA Palm Springs USD 10/11-1 2012-Q4 $ - $ - ### $ 164,354 $ 65,742 $ (98,612)
100 Riverside LGA Palm Springs USD 11/12-1 Err:520 $ 216,770 $ 86,708 $ 130,062 $ - ### $ - 1884
101 Riverside LGA Palm Springs USD 10/11-2 2013-Q1 $ - $ - ### $ 190,760 $ 76,304 $ (114,456)
102 Riverside LGA Palm Springs USD 10/11-3 2013-Q2 $ - $ - ### $ 335,335 $ 134,134 $ (201,201)
103 Riverside LGA Palm Springs USD 11/12-3 Err:520 $ 410,820 $ 164,328 $ 246,492 $ - ### $ - 3463
104 Riverside LGA Palm Springs USD 10/11-4 Err:520 $ 223,061 $ 89,224 $ 133,837 $ - ### $ - 1260
105 Riverside LGA Palm Springs USD 11/12-4 Err:520 $ 282,665 $ 113,066 $ 169,599 $ - ### $ - 4233
106 Palm Springs USD Total $ 1,133,316 $ 453,326 $ 679,990 $ 690,449 $ 276,180 $ (414,269) $ 39,057
107 Riverside LGA Perris ESD 10/11-1 2012-Q4 $ - $ - ### $ 154,175 $ 61,670 $ (92,505)
108 Riverside LGA Perris ESD 11/12-1 Err:520 $ 128,006 $ 51,202 $ 76,804 $ - ### $ - 1885
109 Riverside LGA Perris ESD 10/11-2 2013-Q1 $ - $ - ### $ 111,728 $ 44,691 $ (67,037)
110 Riverside LGA Perris ESD 11/12-2 Err:520 $ 99,245 $ 39,698 $ 59,547 $ - ### $ - 2658
111 Riverside LGA Perris ESD 10/11-3 2013-Q2 $ - $ - ### $ 185,618 $ 74,247 $ (111,371)
112 Riverside LGA Perris ESD 11/12-3 Err:520 $ 156,833 $ 62,733 $ 94,100 $ - ### $ - 3464
113 Riverside LGA Perris ESD 09/10-4 2012-Q3 $ - $ - ### $ 118,943 $ 47,577 $ (71,366)
114 Riverside LGA Perris ESD 10/11-4 Err:520 $ 128,378 $ 51,351 $ 77,027 $ - ### $ - 1261
115 Riverside LGA Perris ESD 12/13-1 Err:520 $ 99,112 $ 39,645 $ 59,467 4999
116 Riverside LGA Perris ESD 12/13-2 Err:520 $ 71,212 $ 28,485 $ 42,727
117 Riverside LGA Perris ESD 12/13-3 Err:520 $ 131,453 $ 52,581 $ 78,872
118 Riverside LGA Perris ESD 11/12-4 Err:520 $ 128,331 $ 51,332 $ 76,999 $ - ### $ - 4234
119 Perris ESD Total $ 942,570 $ 377,027 $ 565,543 $ 570,464 $ 228,185 $ (342,279) $ 34,748
120 Riverside LGA Riverside COE 10/11-1 2012-Q4 $ - $ - ### $ 138,579 $ 55,432 $ (83,147)
121 Riverside LGA Riverside COE 11/12-1 Err:520 $ 58,843 $ 23,537 $ 35,306 $ - ### $ - 1886
122 Riverside LGA Riverside COE 10/11-2 2013-Q1 $ - $ - ### $ 50,626 $ 20,250 $ (30,376)
123 Riverside LGA Riverside COE 11/12-2 Err:520 $ 42,434 $ 31,826 $ 10,608 $ - ### $ - 2 2659
124 Riverside LGA Riverside COE 10/11-3 Err:520 $ 92,446 $ 36,978 $ 55,468 $ - ### $ - 812
125 Riverside LGA Riverside COE 11/12-3 Err:520 $ 63,893 $ 25,557 $ 38,336 $ - ### $ - 3465
126 Riverside LGA Riverside COE 09/10-4 2012-Q3 $ - $ - ### $ 89,841 $ 35,936 $ (53,905)
127 Riverside LGA Riverside COE 10/11-4 Err:520 $ 79,562 $ 31,825 $ 47,737 $ - ### $ - 1262
128 Riverside LGA Riverside COE 11/12-4 Err:520 $ 52,616 $ 21,046 $ 31,570 $ - ### $ - 4235
129 Riverside COE Total $ 389,794 $ 170,769 $ 219,025 $ 279,046 $ 111,618 $ (167,428) $ 3,341
130 Riverside LGA Riverside Community College 11/12-1 Err:520 $ 47,461 $ 35,596 $ 11,865 $ - ### $ - 1 1887
131 Riverside LGA Riverside Community College 11/12-2 Err:520 $ 25,181 $ 18,886 $ 6,295 $ - ### $ - 1 2660
132 Riverside LGA Riverside Community College 10/11-3 Err:520 $ 33,157 $ 24,868 $ 8,289 $ - ### $ - 1 813
133 Riverside LGA Riverside Community College 11/12-3 Err:520 $ 50,376 $ 20,150 $ 30,226 $ - ### $ - 3466
134 Riverside LGA Riverside Community College 10/11-4 Err:520 $ 29,587 $ 22,190 $ 7,397 $ - ### $ - 1 1263
135 Riverside LGA Riverside Community College 11/12-4 Err:520 $ 39,406 $ 29,555 $ 9,851 $ - ### $ - 1 4236
136 Riverside LGA Riverside Community College 10/11-1C-1 2012-Q4 $ - $ - ### $ 27,058 $ 20,294 $ (6,764) 1
137 Riverside Community College Total $ 225,168.00 $ 151,245.00 $ 73,923.00 $ 27,058 $ 20,294 $ (6,764) $ 144,481
138 Riverside LGA Riverside USD 10/11-1 Err:520 $ 466,210 $ - ### $ - 503
139 Riverside LGA Riverside USD 11/12-1 Err:520 $ 525,379 $ 210,152 $ 315,227 $ - ### $ - 1888
140 Riverside LGA Riverside USD 10/11-2 Err:520 $ 819,376 $ 327,750 $ 491,626 $ - ### $ - 608
141 Riverside LGA Riverside USD 11/12-2 Err:520 $ 510,249 $ 204,100 $ 306,149 $ - ### $ - 2661
142 Riverside LGA Riverside USD 10/11-3 Err:520 $ 821,180 $ 328,472 $ 492,708 $ - ### $ - 814
143 Riverside LGA Riverside USD 11/12-3 Err:520 $ 968,616 $ 387,446 $ 581,170 $ - ### $ - 3467
144 Riverside LGA Riverside USD 11/12-4 Err:520 $ 669,658 $ 267,863 $ 401,795 $ - ### $ - 4237
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
145 Riverside USD Total $ 4,780,668 $ 1,725,783 $ 2,588,675 $ - $ - $ - $ 1,725,783
146 Riverside LGA Temecula Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 42,769 $ 32,077 $ (10,692)
147 Riverside LGA Temecula Valley USD 11/12-1 Err:520 $ 91,923 $ 36,769 $ 55,154 $ - ### $ - 1890
148 Riverside LGA Temecula Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 50,649 $ 20,260 $ (30,389)
149 Riverside LGA Temecula Valley USD 11/12-2 Err:520 $ 38,306 $ 28,730 $ 9,576 $ - ### $ - 2 2663
150 Riverside LGA Temecula Valley USD 10/11-3 2013-Q2 $ - $ - ### $ 47,517 $ 35,638 $ (11,879)
151 Riverside LGA Temecula Valley USD 11/12-3 Err:520 $ 61,688 $ 24,675 $ 37,013 $ - ### $ - 3469
152 Riverside LGA Temecula Valley USD 09/10-4 2012-Q3 $ - $ - ### $ 49,635 $ 37,226 $ (12,409)
153 Riverside LGA Temecula Valley USD 10/11-4 Err:520 $ 60,483 $ 24,193 $ 36,290 $ - ### $ - 1265
154 Riverside LGA Temecula Valley USD 11/12-4 Err:520 $ 30,908 $ 25,000 $ 5,908 $ - ### $ - 2 4239
155 Temecula Valley USD Total $ 283,308 $ 139,367 $ 143,941 $ 190,570 $ 125,201 $ (65,369) $ 73,998
156 Grand Total Riverside LGA $ 17,822,942 $ 7,241,616 $ 10,115,116 $ 6,749,669 $ 2,906,566 $ (3,843,103) $ 3,398,513
157
158
159 Column A County - Reporting LEC/LGA
160 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
161 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
162 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
163 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
164 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
165 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
166 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
167 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
168 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
169 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
170 The last subtotal amount is the final amount due to/from the LEC/LGA
171 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
172

173 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
174 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
175 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
176

177 Released Claiming Unit Invoice on placeholder to be paid 100%


178

179 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
180 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
181

182 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
183 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
184 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
185 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
186

187 Claiming units no longer participating (5% reduction)


188
189 12/13 claims
190 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Sacramento LGA Folsom Cordova USD 10/11-1 2012-Q4 $ - $ - ### $ 121,996 $ 48,798 $ (73,198)
3 Sacramento LGA Folsom Cordova USD 11/12-1 Err:520 $ 70,137 $ 28,055 $ 42,082 $ - ### $ - 1891
4 Sacramento LGA Folsom Cordova USD 10/11-2 2013-Q1 $ - $ - ### $ 105,449 $ 42,180 $ (63,269)
5 Sacramento LGA Folsom Cordova USD 11/12-2 Err:520 $ 67,201 $ 26,880 $ 40,321 $ - ### $ - 2664
6 Sacramento LGA Folsom Cordova USD 10/11-3 2013-Q2 $ - $ - ### $ 43,197 $ 32,398 $ (10,799) 2
7 Sacramento LGA Folsom Cordova USD 11/12-3 Err:520 $ 62,577 $ 25,031 $ 37,546 $ - ### $ - 3470
8 Sacramento LGA Folsom Cordova USD 09/10-4 2012-Q3 $ - $ - ### $ 63,529 $ 25,412 $ (38,117)
9 Sacramento LGA Folsom Cordova USD 10/11-4 Err:520 $ 76,528 $ 30,611 $ 45,917 $ - ### $ - 1266
10 Sacramento LGA Folsom Cordova USD 11/12-4 Err:520 $ 51,248 $ 20,499 $ 30,749 $ - ### $ - 4240
11 Sacramento LGA Folsom Cordova USD 12/13-1 Err:520 $ 65,209 $ 26,084 $ 39,125 5005
12 Sacramento LGA Folsom Cordova USD 12/13-2 Err:520 $ 61,913 $ 24,765 $ 37,148 5802
13 Sacramento LGA Folsom Cordova USD 12/13-3 Err:520 $ 49,729 $ 37,297 $ 12,432
14 Folsom Cordova USD Total $ 504,542 $ 219,222 $ 285,320 $ 334,171 $ 148,788 $ (185,383) $ 33,839
15 Sacramento LGA Sacramento City USD 10/11-1 2012-Q4 $ - $ - ### $ 222,582 $ 89,033 $ (133,549)
16 Sacramento LGA Sacramento City USD 11/12-1 Err:520 $ 413,788 $ 165,515 $ 248,273 $ - ### $ - 1893
17 Sacramento LGA Sacramento City USD 10/11-2 2013-Q1 $ - $ - ### $ 339,078 $ 135,631 $ (203,447)
18 Sacramento LGA Sacramento City USD 11/12-2 Err:520 $ 466,620 $ 186,648 $ 279,972 $ - ### $ - 2666
19 Sacramento LGA Sacramento City USD 10/11-3 2013-Q2 $ - $ - ### $ 328,978 $ 131,591 $ (197,387)
20 Sacramento LGA Sacramento City USD 11/12-3 Err:520 $ 477,684 $ 191,074 $ 286,610 $ - ### $ - 3472
21 Sacramento LGA Sacramento City USD 10/11-4 2013-Q3 $ - $ - ### $ 444,752 $ 177,901 $ (266,851)
22 Sacramento LGA Sacramento City USD 11/12-4 Err:520 $ 563,430 $ 225,372 $ 338,058 $ - ### $ - 4242
23 Sacramento LGA Sacramento City USD 12/13-1 Err:520 $ 190,665 $ 76,266 $ 114,399 5007
24 Sacramento City USD Total $ 2,112,187 $ 844,875 $ 1,267,312 $ 1,335,390 $ 534,156 $ (801,234) $ 43,641
25 Sacramento LGA San Juan USD 11/12-1 Err:520 $ 77,738 $ 31,095 $ 46,643 $ - ### $ - 1894
26 Sacramento LGA San Juan USD 11/12-2 Err:520 $ 150,548 $ 60,219 $ 90,329 $ - ### $ - 2667
27 Sacramento LGA San Juan USD 11/12-3 Err:520 $ 169,502 $ 67,801 $ 101,701 $ - ### $ - 3473
28 Sacramento LGA San Juan USD 11/12-4 Err:520 $ 189,661 $ 75,864 $ 113,797 $ - ### $ - 4243
29 San Juan USD Total $ 587,449 $ 234,979 $ 352,470 $ - $ - $ - $ 234,979
30 Sacramento LGA San Juan USD Pupil Health Svcs 10/11-1 2012-Q4 $ - $ - ### $ 40,340 $ 30,255 $ (10,085) 1
31 Sacramento LGA San Juan USD Pupil Health Svcs 10/11-2 2013-Q1 $ - $ - ### $ 64,006 $ 25,602 $ (38,404)
32 Sacramento LGA San Juan USD Pupil Health Svcs 10/11-3 2013-Q2 $ - $ - ### $ 65,030 $ 26,012 $ (39,018)
33 Sacramento LGA San Juan USD Pupil Health Svcs 09/10-4 2012-Q3 $ - $ - ### $ 66,290 $ 26,516 $ (39,774)
34 Sacramento LGA San Juan USD Pupil Health Svcs 10/11-4 Err:520 $ 54,447 $ 21,779 $ 32,668 $ - ### $ - 1269
35 San Juan USD Pupil Health Svcs Total $ 54,447 $ 21,779 $ 32,668 $ 235,666 $ 108,385 $ (127,281) $ (105,502)
36 Grand Total Sacramento LGA $ 3,258,625 $ 1,320,855 $ 1,937,770 $ 1,905,227 $ 791,329 $ (1,113,898) $ 206,957
37
38
39 Column A County - Reporting LEC/LGA
40 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
41 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
42 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
43 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
44 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
45 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
46 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
47 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
48 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
49 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
50 The last subtotal amount is the final amount due to/from the LEC/LGA
51 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
52

53 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
54 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
55 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
56

57 Released Claiming Unit Invoice on placeholder to be paid 100%


58

59 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
60 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
61

62 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
63 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
64 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
65 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
66

67 Claiming units no longer participating (5% reduction)


68
69 12/13 claims
70 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 San Bernardino Adelanto ESD 10/11-1 2012-Q4 $ - $ - ### $ 48,480 $ 33,936 $ (14,544)
3 San Bernardino Adelanto ESD 11/12-1 Err:520 $ 83,205 $ 29,122 $ 54,083 $ - ### $ - 1895
4 San Bernardino Adelanto ESD 10/11-2 2013-Q1 $ - $ - ### $ 32,123 $ 22,486 $ (9,637)
5 San Bernardino Adelanto ESD 11/12-2 Err:520 $ 61,392 $ 21,487 $ 39,905 $ - ### $ - 2668
6 San Bernardino Adelanto ESD 10/11-3 Err:520 $ 33,168 $ 23,218 $ 9,950 $ - ### $ - 816
7 San Bernardino Adelanto ESD 11/12-3 Err:520 $ 35,424 $ 24,797 $ 10,627 $ - ### $ - 3474
8 San Bernardino Adelanto ESD 10/11-4 Err:520 $ 36,640 $ 25,648 $ 10,992 $ - ### $ - 1271
9 San Bernardino Adelanto ESD 11/12-4 Err:520 $ 37,360 $ 26,152 $ 11,208 $ - ### $ - 4244
10 Adelanto ESD Total $ 287,189 $ 150,424 $ 136,765 $ 80,603 $ 56,422 $ (24,181) $ 126,243
11 San Bernardino Alvord USD 10/11-1 2012-Q4 $ - $ - ### $ 96,644 $ 38,658 $ (57,986)
12 San Bernardino Alvord USD 11/12-1 Err:520 $ 129,083 $ 51,633 $ 77,450 $ - ### $ - 1896
13 San Bernardino Alvord USD 10/11-2 2013-Q1 $ - $ - ### $ 97,289 $ 38,916 $ (58,373)
14 San Bernardino Alvord USD 11/12-2 Err:520 $ 89,523 $ 35,809 $ 53,714 $ - ### $ - 2669
15 San Bernardino Alvord USD 10/11-3 Err:520 $ 155,826 $ 62,330 $ 93,496 $ - ### $ - 817
16 San Bernardino Alvord USD 11/12-3 Err:520 $ 187,945 $ 75,178 $ 112,767 $ - ### $ - 3475
17 San Bernardino Alvord USD 09/10-4 2012-Q3 $ - $ - ### $ 86,539 $ 34,616 $ (51,923)
18 San Bernardino Alvord USD 10/11-4 Err:520 $ 148,158 $ 59,263 $ 88,895 $ - ### $ - 1272
19 San Bernardino Alvord USD 11/12-4 Err:520 $ 132,721 $ 53,088 $ 79,633 $ - ### $ - 4246
20 Alvord USD Total $ 843,256 $ 337,301 $ 505,955 $ 280,472 $ 112,190 $ (168,282) $ 169,019
21 San Bernardino Bear Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 66,935 $ 26,774 $ (40,161)
22 San Bernardino Bear Valley USD 11/12-1 Err:520 $ 59,628 $ 23,851 $ 35,777 $ - ### $ - 1897
23 San Bernardino Bear Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 52,829 $ 21,132 $ (31,697)
24 San Bernardino Bear Valley USD 11/12-2 Err:520 $ 61,553 $ 24,621 $ 36,932 $ - ### $ - 2670
25 San Bernardino Bear Valley USD 10/11-3 Err:520 $ 61,130 $ 24,452 $ 36,678 $ - ### $ - 818
26 San Bernardino Bear Valley USD 11/12-3 Err:520 $ 65,391 $ 26,156 $ 39,235 $ - ### $ - 3476
27 San Bernardino Bear Valley USD 09/10-4 2012-Q3 $ - $ - ### $ 41,112 $ 30,834 $ (10,278)
28 San Bernardino Bear Valley USD 10/11-4 Err:520 $ 64,438 $ 25,775 $ 38,663 $ - ### $ - 1273
29 San Bernardino Bear Valley USD 11/12-4 Err:520 $ 59,345 $ 23,738 $ 35,607 $ - ### $ - 4248
30 Bear Valley USD Total $ 371,485 $ 148,593 $ 222,892 $ 160,876 $ 78,740 $ (82,136) $ 66,457
31 San Bernardino Chaffey Joint Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 281,444 $ 112,578 $ (168,866)
32 San Bernardino Chaffey Joint Union HSD 11/12-1 Err:520 $ 459,781 $ 183,912 $ 275,869 $ - ### $ - 1899
33 San Bernardino Chaffey Joint Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 438,062 $ 175,225 $ (262,837)
34 San Bernardino Chaffey Joint Union HSD 11/12-2 Err:520 $ 484,462 $ 193,785 $ 290,677 $ - ### $ - 2672
35 San Bernardino Chaffey Joint Union HSD 10/11-3 Err:520 $ 406,244 $ 162,498 $ 243,746 $ - ### $ - 820
36 San Bernardino Chaffey Joint Union HSD 11/12-3 Err:520 $ 521,681 $ 208,672 $ 313,009 $ - ### $ - 3478
37 San Bernardino Chaffey Joint Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 266,565 $ 106,626 $ (159,939)
38 San Bernardino Chaffey Joint Union HSD 10/11-4 Err:520 $ 377,013 $ 150,805 $ 226,208 $ - ### $ - 1275
39 San Bernardino Chaffey Joint Union HSD 11/12-4 Err:520 $ 345,953 $ 138,381 $ 207,572 $ - ### $ - 4250
40 Chaffey Joint Union HSD Total $ 2,595,134 $ 1,038,053 $ 1,557,081 $ 986,071 $ 394,429 $ (591,642) $ 446,411
41 San Bernardino CSU San Bernardino 11/12-1 Err:520 $ 179,082 $ 62,679 $ 116,403 $ - ### $ - 1900
42 San Bernardino CSU San Bernardino 11/12-2 Err:520 $ 178,861 $ 62,601 $ 116,260 $ - ### $ - 2673
43 San Bernardino CSU San Bernardino 11/12-3 Err:520 $ 138,116 $ 48,341 $ 89,775 $ - ### $ - 3479
44 San Bernardino CSU San Bernardino 10/11-4 Err:520 $ 66,178 $ 23,162 $ 43,016 $ - ### $ - 1276
45 San Bernardino CSU San Bernardino 11/12-4 Err:520 $ 156,785 $ 54,875 $ 101,910 $ - ### $ - 4253
46 CSU San Bernardino Total $ 719,022 $ 251,658 $ 467,364 $ - $ - $ - $ 251,658
47 San Bernardino Cucamonga SD 10/11-2 2013-Q1 $ - $ - ### $ 31,484 $ 22,039 $ (9,445)
48 San Bernardino Cucamonga SD 10/11-3 Err:520 $ 28,527 $ 19,969 $ 8,558 $ - ### $ - 821
49 San Bernardino Cucamonga SD 10/11-4 Err:520 $ 27,100 $ 18,970 $ 8,130 $ - ### $ - 1277
50 San Bernardino Cucamonga SD 11/12-4 Err:520 $ 26,385 $ 18,470 $ 7,915 $ - ### $ - 4254
51 Cucamonga SD Total* $ 82,012 $ 57,409 $ 24,603 $ 31,484 $ 22,039 $ (9,445) $ 47,964
52 San Bernardino Etiwanda ESD 10/11-1 2012-Q4 $ - $ - ### $ 82,008 $ 32,803 $ (49,205)
53 San Bernardino Etiwanda ESD 10/11-2 2013-Q1 $ - $ - ### $ 99,494 $ 39,798 $ (59,696)
54 San Bernardino Etiwanda ESD 11/12-1 Err:520 $ 71,838 $ 28,735 $ 43,103 $ - ### $ - 1902
55 San Bernardino Etiwanda ESD 11/12-2 Err:520 $ 89,775 $ 35,910 $ 53,865 $ - ### $ - 2675
56 San Bernardino Etiwanda ESD 11/12-3 Err:520 $ 69,757 $ 27,903 $ 41,854 $ - ### $ - 3481
57 San Bernardino Etiwanda ESD 11/12-4 Err:520 $ 58,898 $ 23,559 $ 35,339 $ - ### $ - 4255
58 San Bernardino Etiwanda ESD 10/11-3 Err:520 $ 94,245 $ 37,698 $ 56,547 $ - ### $ - 822
59 San Bernardino Etiwanda ESD 10/11-4 Err:520 $ 107,604 $ 43,042 $ 64,562 $ - ### $ - 1278
60 San Bernardino Etiwanda ESD 09/10-4C-1 2012-Q3 $ - $ - ### $ 76,636 $ 30,654 $ (45,982)
61 Etiwanda ESD Total $ 492,117.00 $ 196,847.00 $ 295,270.00 $ 258,138 $ 103,255 $ (154,883) $ 41,964
62 San Bernardino Fontana USD 10/11-1 2012-Q4 $ - $ - ### $ 184,681 $ 73,872 $ (110,809)
63 San Bernardino Fontana USD 11/12-1 Err:520 $ 162,003 $ 64,801 $ 97,202 $ - ### $ - 1903
64 San Bernardino Fontana USD 10/11-2 2013-Q1 $ - $ - ### $ 188,469 $ 75,388 $ (113,081)
65 San Bernardino Fontana USD 11/12-2 Err:520 $ 130,789 $ 52,316 $ 78,473 $ - ### $ - 2676
66 San Bernardino Fontana USD 10/11-3 Err:520 $ 172,189 $ 68,876 $ 103,313 $ - ### $ - 823
67 San Bernardino Fontana USD 11/12-3 Err:520 $ 178,139 $ 71,256 $ 106,883 $ - ### $ - 3482
68 San Bernardino Fontana USD 09/10-4 2012-Q3 $ - $ - ### $ 196,707 $ 78,683 $ (118,024)
69 San Bernardino Fontana USD 10/11-4 Err:520 $ 240,641 $ 96,256 $ 144,385 $ - ### $ - 1279
70 San Bernardino Fontana USD 11/12-4 Err:520 $ 146,398 $ 58,559 $ 87,839 $ - ### $ - 4256
71 Fontana USD Total $ 1,030,159 $ 412,064 $ 618,095 $ 569,857 $ 227,943 $ (341,914) $ 70,150
72 San Bernardino Hesperia USD 10/11-1 2012-Q4 $ - $ - ### $ 68,038 $ 23,813 $ (44,225)
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
73 San Bernardino Hesperia USD 11/12-1 Err:520 $ 38,794 $ 27,156 $ 11,638 $ - ### $ - 1904
74 San Bernardino Hesperia USD 10/11-2 2013-Q1 $ - $ - ### $ 84,966 $ 29,738 $ (55,228)
75 San Bernardino Hesperia USD 11/12-2 Err:520 $ 65,076 $ 22,777 $ 42,299 $ - ### $ - 2677
76 San Bernardino Hesperia USD 10/11-3 Err:520 $ 85,469 $ 29,914 $ 55,555 $ - ### $ - 824
77 San Bernardino Hesperia USD 11/12-3 Err:520 $ 60,069 $ 21,024 $ 39,045 $ - ### $ - 3483
78 San Bernardino Hesperia USD 09/10-4 2012-Q3 $ - $ - ### $ 104,832 $ 36,691 $ (68,141)
79 San Bernardino Hesperia USD 10/11-4 Err:520 $ 82,107 $ 28,737 $ 53,370 $ - ### $ - 1280
80 San Bernardino Hesperia USD 12/13-1 Err:520 $ 13,786 $ 13,786 $ - 5022
81 San Bernardino Hesperia USD 11/12-4 Err:520 $ 42,546 $ 29,782 $ 12,764 $ - ### $ - 4257
82 Hesperia USD Total $ 387,847 $ 173,176 $ 214,671 $ 257,836 $ 90,242 $ (167,594) $ 5,582
83 San Bernardino Lake Elsinore USD 10/11-1 2012-Q4 $ - $ - ### $ 102,110 $ 40,844 $ (61,266)
84 San Bernardino Lake Elsinore USD 11/12-1 Err:520 $ 126,175 $ 50,470 $ 75,705 $ - ### $ - 1905
85 San Bernardino Lake Elsinore USD 10/11-2 2013-Q1 $ - $ - ### $ 60,966 $ 24,386 $ (36,580)
86 San Bernardino Lake Elsinore USD 11/12-2 Err:520 $ 93,095 $ 37,238 $ 55,857 $ - ### $ - 2678
87 San Bernardino Lake Elsinore USD 10/11-3 2013-Q2 $ - $ - ### $ 89,677 $ 35,871 $ (53,806)
88 San Bernardino Lake Elsinore USD 11/12-3 Err:520 $ 193,260 $ 77,304 $ 115,956 $ - ### $ - 3484
89 San Bernardino Lake Elsinore USD 09/10-4 2012-Q3 $ - $ - ### $ 102,333 $ 40,933 $ (61,400)
90 San Bernardino Lake Elsinore USD 10/11-4 Err:520 $ 87,756 $ 35,102 $ 52,654 $ - ### $ - 1281
91 San Bernardino Lake Elsinore USD 11/12-4 Err:520 $ 140,852 $ 56,341 $ 84,511 $ - ### $ - 4258
92 Lake Elsinore USD Total $ 641,138 $ 256,455 $ 384,683 $ 355,086 $ 142,034 $ (213,052) $ 43,403
93 San Bernardino Morongo USD 10/11-2 2013-Q1 $ - $ - ### $ 51,624 $ 20,650 $ (30,974)
94 San Bernardino Morongo USD 11/12-2 Err:520 $ 40,412 $ 30,309 $ 10,103 $ - ### $ - 2 2679
95 San Bernardino Morongo USD 10/11-3 Err:520 $ 37,672 $ 28,254 $ 9,418 $ - ### $ - 2 825
96 San Bernardino Morongo USD 11/12-3 Err:520 $ 25,737 $ 25,000 $ 737 $ - ### $ - 2 3485
97 San Bernardino Morongo USD 10/11-4 Err:520 $ 34,645 $ 25,984 $ 8,661 $ - ### $ - 2 1282
98 San Bernardino Morongo USD 11/12-4 Err:520 $ 40,990 $ 30,743 $ 10,247 $ - ### $ - 2 4259
99 Morongo USD Total $ 179,456 $ 140,290 $ 39,166 $ 51,624 $ 20,650 $ (30,974) $ 109,316
100 San Bernardino Mountain View SD 10/11-2 2013-Q1 $ - $ - ### $ 25,567 $ 17,897 $ (7,670)
101 San Bernardino Mountain View ESD 11/12-4 Err:520 $ 26,155 $ 18,309 $ 7,846 $ - ### $ - 4260
102 San Bernardino Mountain View SD 10/11-3 Err:520 $ 27,275 $ 19,093 $ 8,182 $ - ### $ - 826
103 San Bernardino Mountain View SD 09/10-4 2012-Q3 $ - $ - ### $ 25,443 $ 17,810 $ (7,633)
104 San Bernardino Mountain View SD 10/11-4 Err:520 $ 29,171 $ 20,420 $ 8,751 $ - ### $ - 1283
105 Mountain View SD Total* $ 82,601 $ 57,822 $ 24,779 $ 51,010 $ 35,707 $ (15,303) $ 42,519
106 San Bernardino Perris Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 80,820 $ 32,328 $ (48,492)
107 San Bernardino Perris Union HSD 11/12-1 Err:520 $ 32,424 $ 25,000 $ 7,424 $ - ### $ - 2 1909
108 San Bernardino Perris UHSD 10/11-2 Err:520 $ 35,204 $ 26,403 $ 8,801 $ - ### $ - 609
109 San Bernardino Perris Union HSD 10/11-3 Err:520 $ 38,990 $ 29,243 $ 9,747 $ - ### $ - 828
110 San Bernardino Perris Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 37,383 $ 28,037 $ (9,346)
111 San Bernardino Perris Union HSD 10/11-4 Err:520 $ 26,254 $ 25,000 $ 1,254 $ - ### $ - 2 1285
112 Perris Union HSD Total* $ 132,872 $ 105,646 $ 27,226 $ 118,203 $ 60,365 $ (57,838) $ 47,808
113 San Bernardino Redlands USD 10/11-1 2012-Q4 $ - $ - ### $ 74,243 $ 29,697 $ (44,546)
114 San Bernardino Redlands USD 11/12-1 Err:520 $ 82,242 $ 32,897 $ 49,345 $ - ### $ - 1910
115 San Bernardino Redlands USD 10/11-2 2013-Q1 $ - $ - ### $ 68,039 $ 27,216 $ (40,823)
116 San Bernardino Redlands USD 11/12-2 Err:520 $ 68,176 $ 27,270 $ 40,906 $ - ### $ - 2683
117 San Bernardino Redlands USD 10/11-3 Err:520 $ 45,989 $ 34,492 $ 11,497 $ - ### $ - 2 829
118 San Bernardino Redlands USD 11/12-3 Err:520 $ 68,440 $ 27,376 $ 41,064 $ - ### $ - 3489
119 San Bernardino Redlands USD 09/10-4 2012-Q3 $ - $ - ### $ 49,127 $ 36,845 $ (12,282) 2
120 San Bernardino Redlands USD 10/11-4 Err:520 $ 56,361 $ 22,544 $ 33,817 $ - ### $ - 1286
121 San Bernardino Redlands USD 11/12-4 Err:520 $ 68,980 $ 27,592 $ 41,388 $ - ### $ - 4264
122 Redlands USD Total $ 390,188 $ 172,171 $ 218,017 $ 191,409 $ 93,758 $ (97,651) $ 74,520
123 San Bernardino Rim of the World USD 11/12-2 Err:520 $ 27,276 $ 25,000 $ 2,276 $ - ### $ - 2 2685
124 San Bernardino Rim of the World USD 09/10-4 2012-Q3 $ - $ - ### $ 34,495 $ 25,871 $ (8,624) 2
125 San Bernardino Rim of the World USD 11/12-4 Err:520 $ 26,649 $ 25,000 $ 1,649 $ - ### $ - 2 4266
126 Rim of the World USD Total $ 53,925 $ 50,000 $ 3,925 $ 34,495 $ 25,871 $ (8,624) $ 41,376
127 San Bernardino San Bernardino City USD 10/11-1 Err:520 $ 32,834 $ - ### $ - 2 504
128 San Bernardino San Bernardino City USD 11/12-1 Err:520 $ 82,735 $ 33,094 $ 49,641 $ - ### $ - 1912
129 San Bernardino San Bernardino City USD 10/11-2 Err:520 $ 45,378 $ 34,034 $ 11,344 $ - ### $ - 611
130 San Bernardino San Bernardino City USD 11/12-2 Err:520 $ 31,033 $ 25,000 $ 6,033 $ - ### $ - 2 2686
131 San Bernardino San Bernardino City USD 10/11-3 Err:520 $ 68,028 $ 27,211 $ 40,817 $ - ### $ - 832
132 San Bernardino San Bernardino City USD 11/12-3 Err:520 $ 61,537 $ 24,615 $ 36,922 $ - ### $ - 3491
133 San Bernardino San Bernardino City USD 09/10-4 2012-Q3 $ - $ - ### $ 53,147 $ 21,259 $ (31,888)
134 San Bernardino San Bernardino City USD 10/11-4 Err:520 $ 35,733 $ 26,800 $ 8,933 $ - ### $ - 1288
135 San Bernardino San Bernardino City USD 11/12-4 Err:520 $ 59,826 $ 23,930 $ 35,896 $ - ### $ - 4267
136 San Bernardino City USD Total $ 417,104 $ 194,684 $ 189,586 $ 53,147 $ 21,259 $ (31,888) $ 162,796
137 San Bernardino San Bernardino CSS - D/M SELPA 10/11-1 2012-Q4 $ - $ - ### $ 90,568 $ 36,227 $ (54,341)
138 San Bernardino San Bernardino CSS - D/M SELPA 11/12-1 Err:520 $ 96,210 $ 38,484 $ 57,726 $ - ### $ - 1913
139 San Bernardino San Bernardino CSS - D/M SELPA 10/11-2 2013-Q1 $ - $ - ### $ 70,413 $ 28,165 $ (42,248)
140 San Bernardino San Bernardino CSS - D/M SELPA 11/12-2 Err:520 $ 90,932 $ 36,373 $ 54,559 $ - ### $ - 2687
141 San Bernardino San Bernardino CSS - D/M SELPA 10/11-3 Err:520 $ 70,685 $ 28,274 $ 42,411 $ - ### $ - 833
142 San Bernardino San Bernardino CSS - D/M SELPA 11/12-3 Err:520 $ 83,087 $ 33,235 $ 49,852 $ - ### $ - 3492
143 San Bernardino San Bernardino CSS - D/M SELPA 10/11-4 Err:520 $ 89,869 $ 35,948 $ 53,921 $ - ### $ - 1289
144 San Bernardino San Bernardino CSS - D/M SELPA 11/12-4 Err:520 $ 84,717 $ 33,887 $ 50,830 $ - ### $ - 4268
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
145 San Bernardino CSS - D/M SELPA Total $ 515,500 $ 206,201 $ 309,299 $ 160,981 $ 64,392 $ (96,589) $ 109,612
146 San Bernardino SBCSS - Student Services 09/10-4 2012-Q3 $ - $ - ### $ 31,357 $ 25,000 $ (6,357) 2
147 San Bernardino SBCSS - Student Services 12/13-2 Err:520 $ 4,972 $ 4,475 $ 497 5824
148 San Bernardino SBCSS - Student Services 12/13-3 Err:520 $ 2,240 $ 2,016 $ 224 6598
149 SBCSS - Student Services Total $ 7,212 $ 6,491 $ 721 $ 31,357 $ 25,000 $ (6,357) $ 134
150 San Bernardino San Jacinto USD 10/11-1 2012-Q4 $ - $ - ### $ 40,487 $ 30,365 $ (10,122)
151 San Bernardino San Jacinto USD 11/12-1 Err:520 $ 72,810 $ 29,124 $ 43,686 $ - ### $ - 1915
152 San Bernardino San Jacinto USD 10/11-2 2013-Q1 $ - $ - ### $ 53,132 $ 21,253 $ (31,879)
153 San Bernardino San Jacinto USD 11/12-2 Err:520 $ 84,625 $ 33,850 $ 50,775 $ - ### $ - 2689
154 San Bernardino San Jacinto USD 10/11-3 2013-Q2 $ - $ - ### $ 77,034 $ 30,814 $ (46,220)
155 San Bernardino San Jacinto USD 11/12-3 Err:520 $ 102,013 $ 40,805 $ 61,208 $ - ### $ - 3494
156 San Bernardino San Jacinto USD 09/10-4 2012-Q3 $ - $ - ### $ 68,351 $ 27,340 $ (41,011)
157 San Bernardino San Jacinto USD 10/11-4 Err:520 $ 73,112 $ 29,245 $ 43,867 $ - ### $ - 1290
158 San Bernardino San Jacinto USD 11/12-4 Err:520 $ 84,389 $ 33,756 $ 50,633 $ - ### $ - 4270
159 San Jacinto USD Total $ 416,949 $ 166,780 $ 250,169 $ 239,004 $ 109,772 $ (129,232) $ 37,548
160 San Bernardino Snowline Joint USD 10/11-1 2012-Q4 $ - $ - ### $ 38,388 $ 28,791 $ (9,597)
161 San Bernardino Snowline Joint USD 11/12-1 Err:520 $ 36,460 $ 27,345 $ 9,115 $ - ### $ - 1916
162 San Bernardino Snowline Joint USD 10/11-2 2013-Q1 $ - $ - ### $ 165,475 $ 66,190 $ (99,285)
163 San Bernardino Snowline Joint USD 11/12-2 Err:520 $ 73,685 $ 29,474 $ 44,211 $ - ### $ - 2690
164 San Bernardino Snowline Joint USD 10/11-3 Err:520 $ 108,743 $ 43,497 $ 65,246 $ - ### $ - 834
165 San Bernardino Snowline Joint USD 11/12-3 Err:520 $ 93,513 $ 37,405 $ 56,108 $ - ### $ - 3495
166 San Bernardino Snowline Joint USD 09/10-4 2012-Q3 $ - $ - ### $ 59,866 $ 23,946 $ (35,920)
167 San Bernardino Snowline Joint USD 10/11-4 Err:520 $ 155,113 $ 62,045 $ 93,068 $ - ### $ - 1291
168 San Bernardino Snowline Joint USD 11/12-4 Err:520 $ 84,491 $ 33,796 $ 50,695 $ - ### $ - 4271
169 Snowline Joint USD Total $ 552,005 $ 233,562 $ 318,443 $ 263,729 $ 118,927 $ (144,802) $ 88,760
170 San Bernardino Upland USD 10/11-1 2012-Q4 $ - $ - ### $ 37,968 $ 28,476 $ (9,492) 2
171 San Bernardino Upland USD 11/12-1 Err:520 $ 40,107 $ 30,080 $ 10,027 $ - ### $ - 2 1917
172 San Bernardino Upland USD 10/11-2 2013-Q1 $ - $ - ### $ 48,093 $ 36,070 $ (12,023) 2
173 San Bernardino Upland USD 11/12-2 Err:520 $ 50,513 $ 20,205 $ 30,308 $ - ### $ - 2 2691
174 San Bernardino Upland USD 10/11-3 2013-Q2 $ - $ - ### $ 37,315 $ 27,986 $ (9,329) 2
175 San Bernardino Upland USD 11/12-3 Err:520 $ 48,010 $ 36,008 $ 12,002 $ - ### $ - 2 3496
176 San Bernardino Upland USD 09/10-4 2012-Q3 $ - $ - ### $ 31,413 $ 25,000 $ (6,413) 2
177 San Bernardino Upland USD 10/11-4 Err:520 $ 55,648 $ 22,259 $ 33,389 $ - ### $ - 1292
178 San Bernardino Upland USD 11/12-4 Err:520 $ 53,011 $ 21,204 $ 31,807 $ - ### $ - 4272
179 Upland USD Total $ 247,289 $ 129,756 $ 117,533 $ 154,789 $ 117,532 $ (37,257) $ 92,499
180 San Bernardino Val Verde USD 10/11-1 2012-Q4 $ - $ - ### $ 193,238 $ 77,295 $ (115,943)
181 San Bernardino Val Verde USD 11/12-1 Err:520 $ 212,551 $ 85,020 $ 127,531 $ - ### $ - 1918
182 San Bernardino Val Verde USD 10/11-2 2013-Q1 $ - $ - ### $ 229,674 $ 91,870 $ (137,804)
183 San Bernardino Val Verde USD 11/12-2 Err:520 $ 177,284 $ 70,914 $ 106,370 $ - ### $ - 2692
184 San Bernardino Val Verde USD 10/11-3 Err:520 $ 313,288 $ 125,315 $ 187,973 $ - ### $ - 835
185 San Bernardino Val Verde USD 11/12-3 Err:520 $ 320,116 $ 128,046 $ 192,070 $ - ### $ - 3497
186 San Bernardino Val Verde USD 09/10-4 2012-Q3 $ - $ - ### $ 259,764 $ 103,906 $ (155,858)
187 San Bernardino Val Verde USD 10/11-4 Err:520 $ 211,290 $ 84,516 $ 126,774 $ - ### $ - 1293
188 San Bernardino Val Verde USD 11/12-4 Err:520 $ 235,345 $ 94,138 $ 141,207 $ - ### $ - 4273
189 Val Verde USD Total $ 1,469,874 $ 587,949 $ 881,925 $ 682,676 $ 273,071 $ (409,605) $ 178,344
190 San Bernardino Victor ESD 10/11-1 2012-Q4 $ - $ - ### $ 38,012 $ 28,509 $ (9,503)
191 San Bernardino Victor ESD 11/12-1 Err:520 $ 38,581 $ 28,936 $ 9,645 $ - ### $ - 1919
192 San Bernardino Victor ESD 11/12-2 Err:520 $ 48,691 $ 36,518 $ 12,173 $ - ### $ - 2693
193 San Bernardino Victor ESD 09/10-4 2012-Q3 $ - $ - ### $ 27,396 $ 25,000 $ (2,396) 2
194 San Bernardino Victor ESD 10/11-4 Err:520 $ 33,860 $ 25,395 $ 8,465 $ - ### $ - 1294
195 Victor ESD Total $ 121,132 $ 90,849 $ 30,283 $ 65,408 $ 53,509 $ (11,899) $ 78,950
196 San Bernardino Victor Valley Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 131,779 $ 46,123 $ (85,656)
197 San Bernardino Victor Valley Union HSD 11/12-1 Err:520 $ 162,833 $ 56,992 $ 105,841 $ - ### $ - 1920
198 San Bernardino Victor Valley Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 117,034 $ 40,962 $ (76,072)
199 San Bernardino Victor Valley Union HSD 11/12-2 Err:520 $ 135,078 $ 47,277 $ 87,801 $ - ### $ - 2694
200 San Bernardino Victor Valley Union HSD 10/11-3 Err:520 $ 103,748 $ 36,312 $ 67,436 $ - ### $ - 837
201 San Bernardino Victor Valley Union HSD 11/12-3 Err:520 $ 134,459 $ 47,061 $ 87,398 $ - ### $ - 3499
202 San Bernardino Victor Valley Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 100,608 $ 35,213 $ (65,395)
203 San Bernardino Victor Valley Union HSD 10/11-4 Err:520 $ 131,093 $ 45,883 $ 85,210 $ - ### $ - 1295
204 San Bernardino Victor Valley Union HSD 11/12-4 Err:520 $ 153,794 $ 53,828 $ 99,966 $ - ### $ - 4275
205 Victor Valley Union HSD Total $ 821,005 $ 287,353 $ 533,652 $ 349,421 $ 122,298 $ (227,123) $ 60,230
206 San Bernardino Yucaipa-Calimesa JUSD 10/11-1 2012-Q4 $ - $ - ### $ 53,774 $ 18,821 $ (34,953)
207 San Bernardino Yucaipa-Calimesa JUSD 11/12-1 Err:520 $ 43,549 $ 30,484 $ 13,065 $ - ### $ - 1921
208 San Bernardino Yucaipa-Calimesa JUSD 10/11-2 2013-Q1 $ - $ - ### $ 58,179 $ 20,363 $ (37,816)
209 San Bernardino Yucaipa-Calimesa JUSD 11/12-2 Err:520 $ 47,712 $ 33,398 $ 14,314 $ - ### $ - 2695
210 San Bernardino Yucaipa-Calimesa JUSD 10/11-3 Err:520 $ 48,691 $ 34,084 $ 14,607 $ - ### $ - 838
211 San Bernardino Yucaipa-Calimesa JUSD 11/12-3 Err:520 $ 44,837 $ 31,386 $ 13,451 $ - ### $ - 3500
212 San Bernardino Yucaipa-Calimesa JUSD 09/10-4 2012-Q3 $ - $ - ### $ 68,602 $ 24,011 $ (44,591)
213 San Bernardino Yucaipa-Calimesa JUSD 10/11-4 Err:520 $ 62,036 $ 21,713 $ 40,323 $ - ### $ - 1296
214 San Bernardino Yucaipa-Calimesa JUSD 11/12-4 Err:520 $ 35,738 $ 25,017 $ 10,721 $ - ### $ - 4276
215 Yucaipa-Calimesa JUSD Total $ 282,563 $ 176,082 $ 106,481 $ 180,555 $ 63,195 $ (117,360) $ 58,722
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
216 Grand Total San Bernardino LEC Err:502 Err:502 Err:502 Err:502 Err:502 Err:502 Err:502
217
218
219 Column A County - Reporting LEC/LGA
220 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
221 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
222 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
223 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
224 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
225 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
226 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
227 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
228 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
229 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
230 The last subtotal amount is the final amount due to/from the LEC/LGA
231 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
232

233 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
234 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
235 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
236

237 Released Claiming Unit Invoice on placeholder to be paid 100%


238

239 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
240 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
241

242 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
243 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
244 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
245 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
246

247 Claiming units no longer participating (5% reduction)


248
249 12/13 claims
250 13/14 claims
A B C D E F G H I J K L M N O P Q R S T U V

1
Pro-Rata Net Negative Distribution
Total amount
2
Amount to be recouped Amount to withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Column Pro Rata release to 2013 and CUs in Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims J) Percent claiming unit Red) or 2) Chino Valley USD
3 San Bernardino LGA Alta Loma ESD 10/11-1 2012-Q4 $ - $ - ### $ 66,608 $ 23,313 $ (43,295)
4 San Bernardino LGA Alta Loma ESD 11/12-1 Err:520 $ 91,223 $ 31,928 $ 59,295 $ - ### $ -
5 San Bernardino LGA Alta Loma ESD 10/11-2 2013-Q1 $ - $ - ### $ 88,350 $ 30,923 $ (57,427)
6 San Bernardino LGA Alta Loma ESD 11/12-2 Err:520 $ 86,334 $ 30,217 $ 56,117 $ - ### $ -
7 San Bernardino LGA Alta Loma ESD 10/11-3 2013-Q2 $ - $ - ### $ 80,592 $ 28,207 $ (52,385)
8 San Bernardino LGA Alta Loma ESD 11/12-3 Err:520 $ 80,841 $ 28,294 $ 52,547 $ - ### $ -
9 San Bernardino LGA Alta Loma ESD 10/11-4 Err:520 $ 73,596 $ 25,759 $ 47,837 $ - ### $ -
10 San Bernardino LGA Alta Loma ESD 12/13-1 Err:520 $ 15,166 $ 15,166 $ -
11 San Bernardino LGA Alta Loma ESD 12/13-2 Err:520 $ 17,215 $ 17,215 $ -
12 San Bernardino LGA Alta Loma ESD 12/13-3 Err:520 $ 14,396 $ 14,396 $ -
13 San Bernardino LGA Alta Loma ESD 12/13-4 Err:520 $ 7,143 $ 7,143 $ -
14 San Bernardino LGA Alta Loma ESD 11/12-4 Err:520 $ 27,249 $ 19,074 $ 8,175 $ - ### $ -
15 Alta Loma ESD Total $ 413,163 $ 189,192 $ 223,971 $ 235,550 $ 82,443 $ (153,107) $ 36,085 8.82% $ - $ 36,085 $ 34,330.20
16 San Bernardino LGA Apple Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 30,337 $ 30,337 $ -
17 San Bernardino LGA Apple Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 42,060 $ 42,060 $ -
18 San Bernardino LGA Apple Valley USD 10/11-3 2013-Q2 $ - $ - ### $ 28,024 $ 28,024 $ -
19 San Bernardino LGA Apple Valley USD 12/13-1 Err:520 $ 36,210 $ 27,158 $ 9,052
20 San Bernardino LGA Apple Valley USD 12/13-2 Err:520 $ 21,790 $ 19,611 $ 2,179
21 San Bernardino LGA Apple Valley USD 12/13-3 Err:520 $ 29,796 $ 22,347 $ 7,449
22 San Bernardino LGA Apple Valley USD 12/13-4 Err:520 $ 35,784 $ 26,838 $ 8,946
23 San Bernardino LGA Apple Valley USD 11/12-4 Err:520 $ - $ - $ - ### $ -
24 Apple Valley USD Total $ 123,580 $ 95,954 $ 27,626 $ 100,421 $ 100,421 $ - $ 95,954 23.46% $ - $ 95,954 $ 91,288
25 San Bernardino LGA Barstow USD 10/11-1 2012-Q4 $ - $ - ### $ 26,040 $ 18,228 $ (7,812)
26 San Bernardino LGA Barstow USD 12/13-2 Err:520 $ 4,452 $ 4,452 $ -
27 San Bernardino LGA Barstow USD 12/13-4 Err:520 $ 5,592 $ 5,592 $ -
28 San Bernardino LGA Barstow USD 12/13-3 Err:520 $ 10,911 $ 10,911 $ -
29 Barstow USD Total $ 20,955.00 $ 20,955.00 $ - $ 26,040 $ 18,228 $ (7,812) $ 13,143 3.21% $ - $ 13,143 $ 12,504
30 San Bernardino LGA Chino Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 538,006 $ 188,302 $ (349,704)
31 San Bernardino LGA Chino Valley USD 11/12-1 Err:520 $ 434,533 $ 152,087 $ 282,446 $ - ### $ -
32 San Bernardino LGA Chino Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 712,717 $ 249,451 $ (463,266)
33 San Bernardino LGA Chino Valley USD 11/12-2 Err:520 $ 596,547 $ 208,791 $ 387,756 $ - ### $ -
34 San Bernardino LGA Chino Valley USD 10/11-3 2013-Q2 $ - $ - ### $ 762,887 $ 267,010 $ (495,877)
35 San Bernardino LGA Chino Valley USD 11/12-3 Err:520 $ 598,991 $ 209,647 $ 389,344 $ - ### $ -
36 San Bernardino LGA Chino Valley USD 09/10-4 2012-Q3 $ - $ - ### $ 709,982 $ 248,494 $ (461,488)
37 San Bernardino LGA Chino Valley USD 10/11-4 Err:520 $ 750,491 $ 262,672 $ 487,819 $ - ### $ -
38 San Bernardino LGA Chino Valley USD 12/13-1 Err:520 $ 187,112 $ 65,489 $ 121,623
39 San Bernardino LGA Chino Valley USD 12/13-2 Err:520 $ 263,197 $ 92,119 $ 171,078
40 San Bernardino LGA Chino Valley USD 12/13-3 Err:520 $ 287,363 $ 100,577 $ 186,786
41 San Bernardino LGA Chino Valley USD 12/13-4 Err:520 $ 380,162 $ 133,057 $ 247,105
42 San Bernardino LGA Chino Valley USD 11/12-4 Err:520 $ 447,766 $ 156,718 $ 291,048 $ - ### $ -
43 Chino Valley USD Total $ 3,946,162 $ 1,381,157 $ 2,565,005 $ 2,723,592 $ 953,257 $ (1,770,335) $ (389,178) 100%
44 San Bernardino LGA Colton JUSD 10/11-1 2012-Q4 $ - $ - ### $ 133,102 $ 46,586 $ (86,516)
45 San Bernardino LGA Colton JUSD 11/12-1 Err:520 $ 209,078 $ 73,177 $ 135,901 $ - ### $ -
46 San Bernardino LGA Colton JUSD 10/11-2 2013-Q1 $ - $ - ### $ 101,235 $ 35,432 $ (65,803)
47 San Bernardino LGA Colton JUSD 11/12-2 Err:520 $ 188,909 $ 66,118 $ 122,791 $ - ### $ -
48 San Bernardino LGA Colton JUSD 09/10-3 2012-Q2 $ - $ - ### $ 94,929 $ 33,225 $ (61,704)
49 San Bernardino LGA Colton JUSD 10/11-3 2013-Q2 $ - $ - ### $ 105,839 $ 37,044 $ (68,795)
50 San Bernardino LGA Colton JUSD 11/12-3 Err:520 $ 144,058 $ 50,420 $ 93,638 $ - ### $ -
51 San Bernardino LGA Colton JUSD 09/10-4 2012-Q3 $ - $ - ### $ 81,937 $ 28,678 $ (53,259)
52 San Bernardino LGA Colton JUSD 10/11-4 Err:520 $ 107,278 $ 37,547 $ 69,731 $ - ### $ -
53 San Bernardino LGA Colton JUSD 12/13-1 Err:520 $ 45,540 $ 31,878 $ 13,662
54 San Bernardino LGA Colton JUSD 12/13-2 Err:520 $ 50,740 $ 17,759 $ 32,981
55 San Bernardino LGA Colton JUSD 12/13-3 Err:520 $ 65,192 $ 22,817 $ 42,375
56 San Bernardino LGA Colton JUSD 12/13-4 Err:520 $ 47,190 $ 33,033 $ 14,157
57 San Bernardino LGA Colton JUSD 13/14-3 Err:520 $ 32,230 $ 22,561 $ 9,669
58 San Bernardino LGA Colton JUSD 13/14-4 Err:520 $ 26,994 $ 18,896 $ 8,098
59 San Bernardino LGA Colton JUSD 11/12-4 Err:520 $ 61,155 $ 21,404 $ 39,751 $ - ### $ -
60 Colton JUSD Total $ 978,364 $ 395,610 $ 582,754 $ 517,042 $ 180,965 $ (336,077) $ 59,533 14.55% $ - $ 59,533 $ 56,638
61 San Bernardino LGA Ontario-Montclair SD 10/11-1 2012-Q4 $ - $ - ### $ 309,092 $ 123,637 $ (185,455)
62 San Bernardino LGA Ontario-Montclair SD 10/11-4 Err:520 $ 395,875 $ 158,350 $ 237,525 $ - ### $ -
63 San Bernardino LGA Ontario-Montclair SD 11/12-1 Err:520 $ 337,744 $ 135,098 $ 202,646 $ - ### $ -
64 San Bernardino LGA Ontario-Montclair SD 10/11-2 2013-Q1 $ - $ - ### $ 356,249 $ 142,500 $ (213,749)
65 San Bernardino LGA Ontario-Montclair SD 11/12-2 Err:520 $ 368,919 $ 147,568 $ 221,351 $ - ### $ -
66 San Bernardino LGA Ontario-Montclair SD 09/10-3 2012-Q2 $ - $ - ### $ 401,692 $ 160,677 $ (241,015)
67 San Bernardino LGA Ontario-Montclair SD 10/11-3 2013-Q2 $ - $ - ### $ 323,668 $ 129,467 $ (194,201)
68 San Bernardino LGA Ontario-Montclair SD 11/12-3 Err:520 $ 324,267 $ 129,707 $ 194,560 $ - ### $ -
69 San Bernardino LGA Ontario-Montclair SD 09/10-4 2012-Q3 $ - $ - ### $ 333,788 $ 133,515 $ (200,273)
70 San Bernardino LGA Ontario-Montclair SD 12/13-1 Err:520 $ 89,213 $ 35,685 $ 53,528
71 San Bernardino LGA Ontario-Montclair SD 12/13-2 Err:520 $ 156,549 $ 62,620 $ 93,929
72 San Bernardino LGA Ontario-Montclair SD 12/13-3 Err:520 $ 166,130 $ 66,452 $ 99,678
73 San Bernardino LGA Ontario-Montclair SD 12/13-4 Err:520 $ 167,621 $ 67,048 $ 100,573
74 San Bernardino LGA Ontario-Montclair SD 13/14-1 Err:520 $ 65,512 $ 26,205 $ 39,307
75 San Bernardino LGA Ontario-Montclair SD 13/14-2 Err:520 $ 161,146 $ 64,458 $ 96,688
76 San Bernardino LGA Ontario-Montclair SD 13/14-3 Err:520 $ 177,794 $ 71,118 $ 106,676
77 San Bernardino LGA Ontario-Montclair SD 11/12-4 Err:520 $ 189,605 $ 75,842 $ 113,763 $ - ### $ -
78 Ontario-Montclair SD Total $ 2,600,375 $ 1,040,151 $ 1,560,224 $ 1,724,489 $ 689,796 $ (1,034,693) $ 5,458 1.33% $ - $ 5,458 $ 5,193
79 San Bernardino LGA Rialto USD 10/11-1 2012-Q4 $ - $ - ### $ 164,521 $ 65,808 $ (98,713)
80 San Bernardino LGA Rialto USD 11/12-1 Err:520 $ 208,363 $ 83,345 $ 125,018 $ - ### $ -
81 San Bernardino LGA Rialto USD 11/12-2 Err:520 $ 319,682 $ 127,873 $ 191,809 $ - ### $ -
82 San Bernardino LGA Rialto USD 10/11-2 2013-Q1 $ - $ - ### $ 118,910 $ 47,564 $ (71,346)
83 San Bernardino LGA Rialto USD 10/11-3 Err:520 $ 121,305 $ 48,522 $ 72,783 $ - ### $ -
84 San Bernardino LGA Rialto USD 11/12-3 Err:520 $ 219,072 $ 87,629 $ 131,443 $ - ### $ -
85 San Bernardino LGA Rialto USD 09/10-4 2012-Q3 $ - $ - ### $ 339,659 $ 135,864 $ (203,795)
86 San Bernardino LGA Rialto USD 10/11-4 Err:520 $ 106,950 $ 42,780 $ 64,170 $ - ### $ -
87 San Bernardino LGA Rialto USD 12/13-1 Err:520 $ 39,509 $ 29,632 $ 9,877
88 San Bernardino LGA Rialto USD 12/13-2 Err:520 $ 47,972 $ 35,979 $ 11,993
89 San Bernardino LGA Rialto USD 12/13-3 Err:520 $ 24,541 $ 22,087 $ 2,454
90 San Bernardino LGA Rialto USD 12/13-4 Err:520 $ 34,541 $ 25,906 $ 8,635
91 San Bernardino LGA Rialto USD 11/12-4 Err:520 $ 172,497 $ 68,999 $ 103,498 $ - ### $ -
92 Rialto USD Total $ 1,294,432 $ 572,752 $ 721,680 $ 623,090 $ 249,236 $ (373,854) $ 198,898 48.62% $ - $ 198,898 $ 189,226
93 Grand Total San Bernardino LGA Err:502 Err:502 Err:502 Err:502 Err:502 Err:502 Err:502 100% $ - $ 409,071 $ 389,178
94 The sum of Column N equals the sum of "Column K" (Net Total) minus
95 the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
96 Column A County - Reporting LEC/LGA
97 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12 Pro-Rata Table
98 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Full check amount Check Total $ - <-- Enter check total here
99 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed has not been received Sum of Net Green $ 409,071
100 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment Sum of Net Red $ (389,178)
101 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
102 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
103 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
104 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
105 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
106 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
107 The last subtotal amount is the final amount due to/from the LEC/LGA
108 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
109 Column N The sum of Column N equals the sum of "Column K" (Net Total) minus the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
A B C D E F G H I J K L M N O P Q R S T U V

Total amount
2
Amount to be recouped Amount to withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Column Pro Rata release to 2013 and CUs in Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims J) Percent claiming unit Red) or 2) Chino Valley USD
110 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
111 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
112 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
113

114 Released Claiming Unit Invoice on placeholder to be paid 100%


115

116 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
117 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
118

119 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
120 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
121 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
122 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
123

124 Claiming units no longer participating (5% reduction)


125
126 12/13 claims
127 13/14 claims
Amount to be recouped
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
San Diego LGA Bonsall Union SD 11/12-2 Err:520 $ 25,362 $ 17,753 $ 7,609 $ - ### $ - 2701
Bonsall Union SD Total $ 25,362 $ 17,753 $ 7,609 $ - $ - $ - $ 17,753
San Diego LGA Chula Vista ESD 10/11-1 2012-Q4 $ - $ - ### $ 76,269 $ 30,508 $ (45,761)
San Diego LGA Chula Vista ESD 11/12-1 Err:520 $ 285,069 $ 114,028 $ 171,041 $ - ### $ - 1929
San Diego LGA Chula Vista ESD 10/11-2 2013-Q1 $ - $ - ### $ 81,412 $ 32,565 $ (48,847)
San Diego LGA Chula Vista ESD 11/12-2 Err:520 $ 291,395 $ 116,558 $ 174,837 $ - ### $ - 2702
San Diego LGA Chula Vista ESD 10/11-3 2013-Q2 $ - $ - ### $ 104,627 $ 41,851 $ (62,776)
San Diego LGA Chula Vista ESD 11/12-3 Err:520 $ 344,516 $ 137,806 $ 206,710 $ - ### $ - 3508
San Diego LGA Chula Vista ESD 10/11-4 Err:520 $ 80,382 $ 32,153 $ 48,229 $ - ### $ - 1304
San Diego LGA Chula Vista ESD 11/12-4 Err:520 $ 271,594 $ 108,638 $ 162,956 $ - ### $ - 4278
Chula Vista ESD Total $ 1,272,956 $ 509,183 $ 763,773 $ 262,308 $ 104,924 $ (157,384) $ 351,799
San Diego LGA Encinitas Union ESD 10/11-1 2012-Q4 $ - $ - ### $ 46,869 $ 32,808 $ (14,061)
San Diego LGA Encinitas Union ESD 11/12-1 Err:520 $ 36,031 $ 25,222 $ 10,809 $ - ### $ - 1930
San Diego LGA Encinitas Union ESD 10/11-2 2013-Q1 $ - $ - ### $ 58,662 $ 20,532 $ (38,130)
San Diego LGA Encinitas Union ESD 11/12-2 Err:520 $ 46,558 $ 32,591 $ 13,967 $ - ### $ - 2703
San Diego LGA Encinitas Union ESD 11/12-3 Err:520 $ 27,810 $ 19,467 $ 8,343 $ - ### $ - 3509
San Diego LGA Encinitas Union ESD 09/10-4 2012-Q3 $ - $ - ### $ 47,690 $ 33,383 $ (14,307)
San Diego LGA Encinitas Union ESD 10/11-4 Err:520 $ 51,405 $ 17,992 $ 33,413 $ - ### $ - 1305
San Diego LGA Encinitas Union ESD 11/12-4 Err:520 $ 39,032 $ 27,322 $ 11,710 $ - ### $ - 4279
San Diego LGA Encinitas Union ESD 10/11-3 Err:520 $ 47,562 $ 33,293 $ 14,269 $ - ### $ - 839
Encinitas Union ESD Total $ 248,398 $ 155,887 $ 92,511 $ 153,221 $ 86,723 $ (66,498) $ 89,389
San Diego LGA Escondido Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 25,841 $ 25,000 $ (841) 2
San Diego LGA Escondido Union HSD 11/12-1 Err:520 $ 38,678 $ 29,009 $ 9,669 $ - ### $ - 2 1931
San Diego LGA Escondido Union HSD 11/12-2 Err:520 $ 34,441 $ 25,831 $ 8,610 $ - ### $ - 2 2704
San Diego LGA Escondido Union HSD 10/11-3 Err:520 $ 31,076 $ 25,000 $ 6,076 $ - ### $ - 2 840
San Diego LGA Escondido Union HSD 11/12-3 Err:520 $ 32,702 $ 25,000 $ 7,702 $ - ### $ - 2 3510
San Diego LGA Escondido Union HSD 09/10-4 2012-Q3 $ - $ - ### $ 31,201 $ 25,000 $ (6,201) 2
Escondido Union HSD Total $ 136,897.00 $ 104,840.00 $ 32,057.00 $ 57,042 $ 50,000 $ (7,042) $ 97,798
San Diego LGA King-Chavez Academy of Excellence 10/11-3 Err:520 $ 50,620 $ 17,717 $ 32,903 $ - ### $ - 841
San Diego LGA King-Chavez Academy of Excellence 10/11-4 Err:520 $ 59,339 $ 20,769 $ 38,570 $ - ### $ - 1307
King-Chavez Academy of Excellence Total $ 109,959 $ 38,486 $ 71,473 $ - $ - $ - $ 38,486
San Diego LGA National School District 10/11-2 2013-Q1 $ - $ - ### $ 25,559 $ 19,169 $ (6,390) 1
San Diego LGA National School District 12/13-1 Err:520 $ 12,253 $ 11,028 $ 1,225 5049
San Diego LGA National School District 12/13-2 Err:520 $ 9,403 $ 8,463 $ 940
San Diego LGA National School District 09/10-4 2012-Q3 $ - $ - ### $ 37,980 $ 28,485 $ (9,495) 1
National School District Total $ 21,656.00 $ 19,491.00 $ 2,165.00 $ 63,539 $ 47,654 $ (15,885) $ 3,606
San Diego LGA South Bay USD 10/11-1 2012-Q4 $ - $ - ### $ 51,341 $ 20,536 $ (30,805)
San Diego LGA South Bay USD 11/12-1 Err:520 $ 39,155 $ 29,366 $ 9,789 $ - ### $ - 1 1938
San Diego LGA South Bay USD 10/11-2 2013-Q1 $ - $ - ### $ 56,562 $ 22,625 $ (33,937)
San Diego LGA South Bay USD 11/12-2 Err:520 $ 63,562 $ 25,425 $ 38,137 $ - ### $ - 2711
San Diego LGA South Bay USD 10/11-3 Err:520 $ 31,251 $ 23,438 $ 7,813 $ - ### $ - 1 843
San Diego LGA South Bay USD 11/12-3 Err:520 $ 135,808 $ 54,323 $ 81,485 $ - ### $ - 3517
San Diego LGA South Bay USD 09/10-4 2012-Q3 $ - $ - ### $ 75,895 $ 30,358 $ (45,537)
San Diego LGA South Bay USD 10/11-4 Err:520 $ 32,111 $ 24,083 $ 8,028 $ - ### $ - 1 1309
San Diego LGA South Bay USD 11/12-4 Err:520 $ 148,539 $ 59,416 $ 89,123 $ - ### $ - 4287
South Bay USD Total $ 450,426 $ 216,051 $ 234,375 $ 183,798 $ 73,519 $ (110,279) $ 105,772
Grand Total San Diego LGA $ 2,265,654 $ 1,061,691 $ 1,203,963 $ 719,908 $ 362,820 $ (357,088) $ 704,603

Column A County - Reporting LEC/LGA


Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
The last subtotal amount is the final amount due to/from the LEC/LGA
Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen

Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row

Released Claiming Unit Invoice on placeholder to be paid 100%

Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made

Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012

Claiming units no longer participating (5% reduction)


Amount to be recouped
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
12/13 claims
13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 San Francisco LGA San Francisco USD 10/11-2 2013-Q1 $ - $ - ### $ 56,970 $ 56,970 $ -
3 San Francisco LGA San Francisco USD 10/11-3 2013-Q2 $ - $ - ### $ 51,802 $ 51,802 $ -
4 San Francisco LGA San Francisco USD 09/10-4 2012-Q3 $ - $ - ### $ 92,227 $ 92,227 $ -
5 San Francisco LGA San Francisco USD 11/12-4 Err:520 $ 147,766 $ 147,766 $ - $ - ### $ - 4289
6 San Francisco LGA San Francisco USD 11/12-2 Err:520 $ - $ - $ - ### $ -
7 San Francisco USD Total $ 147,766 $ 147,766 $ - $ 200,999 $ 200,999 $ - $ 147,766
8 Grand Total San Francisco LGA $ 147,766 $ 147,766 $ - $ 200,999 $ 200,999 $ - $ 147,766
9
10
11 Column A County - Reporting LEC/LGA
12 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
13 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
14 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
15 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
16 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
17 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
18 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
19 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
20 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
21 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
22 The last subtotal amount is the final amount due to/from the LEC/LGA
23 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
24

25 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
26 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
27 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
28

29 Released Claiming Unit Invoice on placeholder to be paid 100%


30

31 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
32 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
33

34 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
35 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
36 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
37 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
38

39 Claiming units no longer participating (5% reduction)


40
41 12/13 claims
42 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 San Luis Obispo LGA Lucia Mar USD 10/11-1 2012-Q4 $ - $ - ### $ 111,412 $ 44,565 $ (66,847)
3 San Luis Obispo LGA Lucia Mar USD 11/12-1 Err:520 $ 105,609 $ 42,244 $ 63,365 $ - ### $ - 1940
4 San Luis Obispo LGA Lucia Mar USD 10/11-2 2013-Q1 $ - $ - ### $ 106,158 $ 42,463 $ (63,695)
5 San Luis Obispo LGA Lucia Mar USD 11/12-2 Err:520 $ 113,581 $ 45,432 $ 68,149 $ - ### $ - 2714
6 San Luis Obispo LGA Lucia Mar USD 10/11-3 2013-Q2 $ - $ - ### $ 131,831 $ 52,732 $ (79,099)
7 San Luis Obispo LGA Lucia Mar USD 11/12-3 Err:520 $ 162,546 $ 65,018 $ 97,528 $ - ### $ - 3519
8 San Luis Obispo LGA Lucia Mar USD 10/11-4 Err:520 $ 111,172 $ 44,469 $ 66,703 $ - ### $ - 1310
9 San Luis Obispo LGA Lucia Mar USD 11/12-4 Err:520 $ 125,935 $ 50,374 $ 75,561 $ - ### $ - 4290
10 Lucia Mar USD Total $ 618,843 $ 247,537 $ 371,306 $ 349,401 $ 139,760 $ (209,641) $ 37,896
11 San Luis Obispo LGA San Luis Coastal USD 10/11-1 2012-Q4 $ - $ - ### $ 98,927 $ 39,571 $ (59,356)
12 San Luis Obispo LGA San Luis Coastal USD 11/12-1 Err:520 $ 90,141 $ 36,056 $ 54,085 $ - ### $ - 1941
13 San Luis Obispo LGA San Luis Coastal USD 10/11-2 2013-Q1 $ - $ - ### $ 108,621 $ 43,448 $ (65,173)
14 San Luis Obispo LGA San Luis Coastal USD 11/12-2 Err:520 $ 117,659 $ 47,064 $ 70,595 $ - ### $ - 2715
15 San Luis Obispo LGA San Luis Coastal USD 10/11-3 2013-Q2 $ - $ - ### $ 163,790 $ 65,516 $ (98,274)
16 San Luis Obispo LGA San Luis Coastal USD 11/12-3 Err:520 $ 218,791 $ 87,516 $ 131,275 $ - ### $ - 3520
17 San Luis Obispo LGA San Luis Coastal USD 10/11-4 Err:520 $ 121,733 $ 48,693 $ 73,040 $ - ### $ - 1311
18 San Luis Obispo LGA San Luis Coastal USD 11/12-4 Err:520 $ 143,227 $ 57,291 $ 85,936 $ - ### $ - 4291
19 San Luis Coastal USD Total $ 691,551 $ 276,620 $ 414,931 $ 371,338 $ 148,535 $ (222,803) $ 53,817
20 San Luis Obispo LGA Templeton USD 11/12-3 Err:520 $ 25,097 $ 17,568 $ 7,529 $ - ### $ - 3521
21 Templeton USD Total $ 25,097 $ 17,568 $ 7,529 $ - $ - $ - $ 17,568
22 Grand Total San Luis Obispo LGA $ 1,335,491 $ 541,725 $ 793,766 $ 720,739 $ 288,295 $ (432,444) $ 109,281
23
24
25 Column A County - Reporting LEC/LGA
26 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
27 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
28 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
29 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
30 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
31 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
32 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
33 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
34 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
35 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
36 The last subtotal amount is the final amount due to/from the LEC/LGA
37 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
38

39 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
40 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
41 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
42

43 Released Claiming Unit Invoice on placeholder to be paid 100%


44

45 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
46 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
47

48 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
49 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
50 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
51 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
52

53 Claiming units no longer participating (5% reduction)


54
55 12/13 claims
56 13/14 claims
A B C D E F G H I J K L M N O P Q

1
Pro-Rata Net Negative Distribution Table

2
Amount to be recouped Amount to
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + release to Total amount withheld (FFY 2013 and
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit CUs in Red) Option (insert 1 or 2) East Side Union HSD Children's Ctr. East Side Union HSD General Admin.
3 Santa Clara LGA Cambrian SD 10/11-1 2012-Q4 $ - $ - ### $ 28,215 $ 25,000 $ (3,215) 2
4 Santa Clara LGA Cambrian SD 11/12-1 Err:520 $ 27,589 $ 25,000 $ 2,589 $ - ### $ - 2
5 Santa Clara LGA Cambrian SD 10/11-2 2013-Q1 $ - $ - ### $ 39,649 $ 29,737 $ (9,912) 2
6 Santa Clara LGA Cambrian SD 11/12-2 Err:520 $ 58,602 $ 23,441 $ 35,161 $ - ### $ -
7 Santa Clara LGA Cambrian SD 10/11-3 2013-Q2 $ - $ - ### $ 44,240 $ 33,180 $ (11,060) 2
8 Santa Clara LGA Cambrian SD 11/12-3 Err:520 $ 46,836 $ 35,127 $ 11,709 $ - ### $ - 2
9 Santa Clara LGA Cambrian SD 10/11-4 2013-Q3 $ - $ - ### $ 35,850 $ 26,888 $ (8,962) 2
10 Santa Clara LGA Cambrian SD 11/12-4 Err:520 $ 59,358 $ 23,743 $ 35,615 $ - ### $ -
11 Cambrian SD Total $ 192,385 $ 107,311 $ 85,074 $ 147,954 $ 114,805 $ (33,149) $ 74,162 12.83% $ - $ 74,162 $ 11,959.23 $ 11,443.31
12 Santa Clara LGA Campbell Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 41,131 $ 30,848 $ (10,283) 2
13 Santa Clara LGA Campbell Union HSD 11/12-1 Err:520 $ 94,454 $ 37,782 $ 56,672 $ - ### $ -
14 Santa Clara LGA Campbell Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 109,015 $ 43,606 $ (65,409)
15 Santa Clara LGA Campbell Union HSD 11/12-2 Err:520 $ 222,140 $ 88,856 $ 133,284 $ - ### $ -
16 Santa Clara LGA Campbell Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 82,968 $ 33,187 $ (49,781)
17 Santa Clara LGA Campbell Union HSD 11/12-3 Err:520 $ 218,418 $ 87,367 $ 131,051 $ - ### $ -
18 Santa Clara LGA Campbell Union HSD 10/11-4 2013-Q3 $ - $ - ### $ 85,631 $ 34,252 $ (51,379)
19 Santa Clara LGA Campbell Union HSD 11/12-4 Err:520 $ 201,282 $ 80,513 $ 120,769 $ - ### $ -
20 Campbell Union HSD Total $ 736,294 $ 294,518 $ 441,776 $ 318,745 $ 141,893 $ (176,852) $ 117,666 20.35% $ - $ 117,666 $ 18,974.60 $ 18,156.05
21 Santa Clara LGA Campbell Union SD 10/11-1 2012-Q4 $ - $ - ### $ 40,475 $ 30,356 $ (10,119) 2
22 Santa Clara LGA Campbell Union SD 11/12-1 Err:520 $ 48,705 $ 36,529 $ 12,176 $ - ### $ - 2
23 Santa Clara LGA Campbell Union SD 10/11-2 2013-Q1 $ - $ - ### $ 139,843 $ 55,937 $ (83,906)
24 Santa Clara LGA Campbell Union SD 11/12-2 Err:520 $ 198,197 $ 79,279 $ 118,918 $ - ### $ -
25 Santa Clara LGA Campbell Union SD 10/11-3 2013-Q2 $ - $ - ### $ 128,425 $ 51,370 $ (77,055)
26 Santa Clara LGA Campbell Union SD 11/12-3 Err:520 $ 160,878 $ 64,351 $ 96,527 $ - ### $ -
27 Santa Clara LGA Campbell Union SD 10/11-4 2013-Q3 $ - $ - ### $ 121,778 $ 48,711 $ (73,067)
28 Santa Clara LGA Campbell Union SD 12/13-1 Err:520 $ 3,707 $ 3,336 $ 371
29 Santa Clara LGA Campbell Union SD 12/13-2 Err:520 $ 28,069 $ 21,052 $ 7,017
30 Santa Clara LGA Campbell Union SD 11/12-4 Err:520 $ 120,730 $ 48,292 $ 72,438 $ - ### $ -
31 Campbell Union SD Total $ 560,286 $ 252,839 $ 307,447 $ 430,521 $ 186,374 $ (244,147) $ 8,692 1.50% $ - $ 8,692 $ 1,401.66 $ 1,341.19
32 Santa Clara LGA East Side Union HSD Children's Ctr. 10/11-1 2012-Q4 $ - $ - ### $ 63,418 $ 25,367 $ (38,051)
33 Santa Clara LGA East Side Union HSD Children's Ctr. 11/12-4 Err:520 $ 59,332 $ 23,733 $ 35,599 $ - ### $ -
34 Santa Clara LGA East Side Union HSD Children's Ctr. 11/12-1 Err:520 $ 46,594 $ 34,946 $ 11,648 $ - ### $ - 2
35 Santa Clara LGA East Side Union HSD Children's Ctr. 10/11-2 2013-Q1 $ - $ - ### $ 101,135 $ 40,454 $ (60,681)
36 Santa Clara LGA East Side Union HSD Children's Ctr. 11/12-2 Err:520 $ 59,706 $ 23,882 $ 35,824 $ - ### $ -
37 Santa Clara LGA East Side Union HSD Children's Ctr. 10/11-3 2013-Q2 $ - $ - ### $ 90,423 $ 36,169 $ (54,254)
38 Santa Clara LGA East Side Union HSD Children's Ctr. 11/12-3 Err:520 $ 59,029 $ 23,612 $ 35,417 $ - ### $ -
39 Santa Clara LGA East Side Union HSD Children's Ctr. 10/11-4 2013-Q3 $ - $ - ### $ 77,366 $ 30,946 $ (46,420)
40 East Side Union HSD Children's Ctr. Total $ 224,661.00 $ 106,173.00 $ 118,488.00 $ 332,342 $ 132,936 $ (199,406) $ (93,233) 51.10%
41 Santa Clara LGA East Side Union HSD General Admin. 10/11-1 2012-Q4 $ - $ - ### $ 141,833 $ 56,733 $ (85,100)
42 Santa Clara LGA East Side Union HSD General Admin. 11/12-1 Err:520 $ 301,426 $ 120,570 $ 180,856 $ - ### $ -
43 Santa Clara LGA East Side Union HSD General Admin. 10/11-2 2013-Q1 $ - $ - ### $ 381,802 $ 152,721 $ (229,081)
44 Santa Clara LGA East Side Union HSD General Admin. 11/12-2 Err:520 $ 449,915 $ 179,966 $ 269,949 $ - ### $ -
45 Santa Clara LGA East Side Union HSD General Admin. 10/11-3 2013-Q2 $ - $ - ### $ 340,076 $ 136,030 $ (204,046)
46 Santa Clara LGA East Side Union HSD General Admin. 11/12-3 Err:520 $ 401,912 $ 160,765 $ 241,147 $ - ### $ -
47 Santa Clara LGA East Side Union HSD General Admin. 10/11-4 2013-Q3 $ - $ - ### $ 248,249 $ 99,300 $ (148,949)
48 Santa Clara LGA East Side Union HSD General Admin. 11/12-4 Err:520 $ 291,659 $ 116,664 $ 174,995 $ - ### $ -
49 East Side Union HSD General Admin. Total $ 1,444,912 $ 577,965 $ 866,947 $ 1,111,960 $ 444,784 $ (667,176) $ (89,211) 48.90%
50 Santa Clara LGA Franklin McKinley SD 11/12-1 Err:520 $ 36,218 $ 27,164 $ 9,054 $ - ### $ - 1
51 Santa Clara LGA Franklin McKinley SD 11/12-2 Err:520 $ 68,504 $ 27,402 $ 41,102 $ - ### $ -
52 Santa Clara LGA Franklin McKinley SD 11/12-3 Err:520 $ 75,830 $ 30,332 $ 45,498 $ - ### $ -
53 Santa Clara LGA Franklin McKinley SD 11/12-4 Err:520 $ 63,255 $ 25,302 $ 37,953 $ - ### $ -
54 Franklin McKinley SD Total $ 243,807 $ 110,200 $ 133,607 $ - $ - $ - $ 110,200 19.06% $ - $ 110,200 $ 17,770.65 $ 17,004.03
55 Santa Clara LGA Luther Burbank SD 10/11-2 2013-Q1 $ - $ - ### $ 36,138 $ 27,104 $ (9,034) 2
56 Santa Clara LGA Luther Burbank SD 11/12-2 Err:520 $ 35,552 $ 26,664 $ 8,888 $ - ### $ - 2
57 Santa Clara LGA Luther Burbank SD 10/11-3 2013-Q2 $ - $ - ### $ 33,127 $ 25,000 $ (8,127) 2
58 Santa Clara LGA Luther Burbank SD 11/12-3 Err:520 $ 27,964 $ 25,000 $ 2,964 $ - ### $ - 2
59 Santa Clara LGA Luther Burbank SD 11/12-4 Err:520 $ 30,987 $ 25,000 $ 5,987 $ - ### $ - 2
60 Luther Burbank SD Total $ 94,503 $ 76,664 $ 17,839 $ 69,265 $ 52,104 $ (17,161) $ 59,503 10.29% $ - $ 59,503 $ 9,595.34 $ 9,181.41
61 Santa Clara LGA Moreland SD 10/11-1 2012-Q4 $ - $ - ### $ 50,461 $ 20,184 $ (30,277)
62 Santa Clara LGA Moreland SD 11/12-1 Err:520 $ 38,465 $ 28,849 $ 9,616 $ - ### $ - 2
63 Santa Clara LGA Moreland SD 10/11-2 2013-Q1 $ - $ - ### $ 87,526 $ 35,010 $ (52,516)
64 Santa Clara LGA Moreland SD 11/12-2 Err:520 $ 55,450 $ 22,180 $ 33,270 $ - ### $ -
65 Santa Clara LGA Moreland SD 10/11-3 2013-Q2 $ - $ - ### $ 49,155 $ 36,866 $ (12,289) 2
66 Santa Clara LGA Moreland SD 11/12-3 Err:520 $ 67,230 $ 26,892 $ 40,338 $ - ### $ -
67 Santa Clara LGA Moreland SD 10/11-4 2013-Q3 $ - $ - ### $ 47,593 $ 35,695 $ (11,898) 2
68 Santa Clara LGA Moreland SD 11/12-4 Err:520 $ 45,082 $ 33,812 $ 11,270 $ - ### $ - 2
69 Moreland SD Total $ 206,227 $ 111,733 $ 94,494 $ 234,735 $ 127,755 $ (106,980) $ 4,753 0.82% $ - $ 4,753 $ 766.46 $ 733.40
70 Santa Clara LGA Orchard SD 11/12-3 Err:520 $ 97,090 $ 38,836 $ 58,254 $ - ### $ -
71 Santa Clara LGA Orchard SD 11/12-4 Err:520 $ 75,660 $ 30,264 $ 45,396 $ - ### $ -
72 Orchard SD Total $ 172,750 $ 69,100 $ 103,650 $ - $ - $ - $ 69,100 11.95% $ - $ 69,100 $ 11,142.94 $ 10,662.24
73 Santa Clara LGA San Jose USD 11/12-1 Err:520 $ 231,972 $ 92,789 $ 139,183 $ - ### $ -
74 Santa Clara LGA San Jose USD 10/11-3 2013-Q2 $ - $ - ### $ 321,315 $ 128,526 $ (192,789)
75 Santa Clara LGA San Jose USD 10/11-4 2013-Q3 $ - $ - ### $ 343,981 $ 137,592 $ (206,389)
76 Santa Clara LGA San Jose USD 11/12-2C-1 Err:520 $ 275,904 $ 110,362 $ 165,542 $ - ### $ -
77 Santa Clara LGA San Jose USD 11/12-3C-1 Err:520 $ 260,888 $ 104,355 $ 156,533 $ - ### $ -
78 Santa Clara LGA San Jose USD 11/12-4C-1 Err:520 $ 274,105 $ 109,642 $ 164,463 $ - ### $ -
79 San Jose USD Total $ 1,042,869 $ 417,148 $ 625,721 $ 665,296 $ 266,118 $ (399,178) $ 17,970 3.11% $ - $ 17,970 $ 2,897.81 $ 2,772.80
80 Santa Clara LGA Union SD 11/12-1 Err:520 $ 44,322 $ 33,242 $ 11,080 $ - ### $ - 2
81 Santa Clara LGA Union SD 11/12-2 Err:520 $ 67,756 $ 27,102 $ 40,654 $ - ### $ -
82 Santa Clara LGA Union SD 11/12-3 Err:520 $ 53,465 $ 21,386 $ 32,079 $ - ### $ -
83 Santa Clara LGA Union SD 11/12-4 Err:520 $ 45,845 $ 34,384 $ 11,461 $ - ### $ - 2
84 Union SD Total $ 211,388 $ 116,114 $ 95,274 $ - $ - $ - $ 116,114 20.08% $ - $ 116,114 $ 18,724.33 $ 17,916.57
85 Grand Total Santa Clara LGA $ 5,130,082 $ 2,239,765 $ 2,890,317 $ 3,310,818 $ 1,466,769 $ (1,844,049) $ 395,716 100% $ - $ 578,160 $ 93,233 $ 89,211
86 The sum of Column N equals the sum of "Column K" (Net Total) minus
87 the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
88 Column A County - Reporting LEC/LGA
89 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
90 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Pro-Rata Table
91 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed Full check amount Check Total <-- Enter check total here
92 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment has not been received Sum of Net Green $ 578,160
93 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made Sum of Net Red $ (182,444)
94 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
95 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
96 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
97 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
98 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
99 The last subtotal amount is the final amount due to/from the LEC/LGA
100 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
101 Column N The sum of Column N equals the sum of "Column K" (Net Total) minus the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
102 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
103 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
104 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
105

106 Released Claiming Unit Invoice on placeholder to be paid 100%


107

108 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
109 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
110

111 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
112 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
113 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
114 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
A B C D E F G H I J K L M N O P Q

2
Amount to be recouped Amount to
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + release to Total amount withheld (FFY 2013 and
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Pro Rata Percent claiming unit CUs in Red) Option (insert 1 or 2) East Side Union HSD Children's Ctr. East Side Union HSD General Admin.
115

116 Claiming units no longer participating (5% reduction)


117
118 12/13 claims
119 13/14 claims
A B C D E F G H I J K L M N O P Q R S T U

1
Pro-Rata Net Negative Distribution Table
Total amount
2 Period of Amount to be recouped withheld (FFY
Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata Amount to release to 2013 and CUs in Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent claiming unit Red) or 2) Salinas Union HSD
3 Santa Cruz Alisal Community Healthy Start FRC 11/12-4 Err:520 $ 26,254 $ 25,000 $ 1,254 $ - ### $ - 2
4 Alisal Community Healthy Start FRC Total $ 26,254 $ 25,000 $ 1,254 $ - $ - $ - $ 25,000 0.98% $ 9,178 $ 15,822 214.61
5 Santa Cruz Alisal Union - Sp. Ed. 11/12-3 Err:520 $ 34,614 $ 25,961 $ 8,653 $ - ### $ - 2
6 Santa Cruz Alisal Union - Sp. Ed. 11/12-4 Err:520 $ 27,111 $ 25,000 $ 2,111 $ - ### $ - 2
7 Alisal Union - Sp. Ed. Total $ 61,725 $ 50,961 $ 10,764 $ - $ - $ - $ 50,961 1.99% $ 18,708 $ 32,253 $ 437
8 Santa Cruz Alum Rock Union ESD 11/12-1 Err:520 $ 67,579 $ 27,032 $ 40,547 $ - ### $ -
9 Santa Cruz Alum Rock Union ESD 10/11-2 2013-Q1 $ - $ - ### $ 71,972 $ 28,789 $ (43,183)
10 Santa Cruz Alum Rock Union ESD 11/12-2 Err:520 $ 87,262 $ 34,905 $ 52,357 $ - ### $ -
11 Santa Cruz Alum Rock Union ESD 10/11-3 2013-Q2 $ - $ - ### $ 59,348 $ 23,739 $ (35,609)
12 Santa Cruz Alum Rock Union ESD 11/12-3 Err:520 $ 80,704 $ 32,282 $ 48,422 $ - ### $ -
13 Santa Cruz Alum Rock Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 69,892 $ 27,957 $ (41,935)
14 Santa Cruz Alum Rock Union ESD 11/12-4 Err:520 $ 80,023 $ 32,009 $ 48,014 $ - ### $ -
15 Alum Rock Union ESD Total $ 315,568 $ 126,228 $ 189,340 $ 201,212 $ 80,485 $ (120,727) $ 5,501 0.21% $ 2,019 $ 3,482 $ 47
16 Santa Cruz Berryessa Union Elementary 10/11-2 Err:520 $ 48,709 $ 36,532 $ 12,177 $ - ### $ - 2
17 Santa Cruz Berryessa Union Elementary 11/12-2 Err:520 $ 66,624 $ 26,650 $ 39,974 $ - ### $ -
18 Santa Cruz Berryessa Union Elementary 11/12-3 Err:520 $ 52,009 $ 20,804 $ 31,205 $ - ### $ -
19 Santa Cruz Berryessa Union Elementary 10/11-3 Err:520 $ 48,998 $ 36,749 $ 12,249 $ - ### $ - 2
20 Santa Cruz Berryessa Union Elementary 10/11-4 Err:520 $ 48,265 $ 36,199 $ 12,066 $ - ### $ - 2
21 Santa Cruz Berryessa Union Elementary 11/12-4 Err:520 $ 63,723 $ 25,489 $ 38,234 $ - ### $ -
22 Berryessa Union Elementary Total* $ 328,328 $ 182,423 $ 145,905 $ - $ - $ - $ 182,423 7.12% $ 66,970 $ 115,453 $ 1,566
23 Santa Cruz Cupertino Union SD 10/11-1 2012-Q4 $ - $ - ### $ 81,463 $ 32,585 $ (48,878)
24 Santa Cruz Cupertino Union SD 11/12-1 Err:520 $ 77,242 $ 30,897 $ 46,345 $ - ### $ -
25 Santa Cruz Cupertino Union SD 10/11-2 2013-Q1 $ - $ - ### $ 126,366 $ 50,546 $ (75,820)
26 Santa Cruz Cupertino Union SD 11/12-2 Err:520 $ 152,039 $ 60,816 $ 91,223 $ - ### $ -
27 Santa Cruz Cupertino Union SD 10/11-3 2013-Q2 $ - $ - ### $ 123,834 $ 49,534 $ (74,300)
28 Santa Cruz Cupertino Union SD 11/12-3 Err:520 $ 130,104 $ 52,042 $ 78,062 $ - ### $ -
29 Santa Cruz Cupertino Union SD 10/11-4 2013-Q3 $ - $ - ### $ 115,279 $ 46,112 $ (69,167)
30 Santa Cruz Cupertino Union SD 12/13-1 Err:520 $ 57,847 $ 23,139 $ 34,708
31 Santa Cruz Cupertino Union SD 12/13-2 Err:520 $ 75,939 $ 30,376 $ 45,563
32 Santa Cruz Cupertino Union SD 12/13-3 Err:520 $ 71,482 $ 28,593 $ 42,889
33 Santa Cruz Cupertino Union SD 11/12-4 Err:520 $ 130,725 $ 52,290 $ 78,435 $ - ### $ -
34 Cupertino Union SD Total $ 695,378 $ 278,153 $ 417,225 $ 446,942 $ 178,777 $ (268,165) $ 9,988 0.39% $ 3,667 $ 6,321 $ 86
35 Santa Cruz Evergreen ESD 10/11-2 2013-Q1 $ - $ - ### $ 40,476 $ 30,357 $ (10,119) 2
36 Santa Cruz Evergreen ESD 11/12-2 Err:520 $ 40,266 $ 30,200 $ 10,066 $ - ### $ - 2
37 Santa Cruz Evergreen ESD 10/11-3 2013-Q2 $ - $ - ### $ 35,044 $ 26,283 $ (8,761) 2
38 Santa Cruz Evergreen ESD 11/12-3 Err:520 $ 32,737 $ 25,000 $ 7,737 $ - ### $ - 2
39 Santa Cruz Evergreen ESD 10/11-4 2013-Q3 $ - $ - ### $ 32,869 $ 25,000 $ (7,869) 2
40 Santa Cruz Evergreen ESD 11/12-4 Err:520 $ 30,346 $ 25,000 $ 5,346 $ - ### $ - 2
41 Evergreen ESD Total $ 103,349 $ 80,200 $ 23,149 $ 108,389 $ 81,640 $ (26,749) $ 53,451 2.09% $ 19,622 $ 33,829 $ 459
42 Santa Cruz Foothill - DeAnza Comm College Dist 10/11-1 2012-Q4 $ - $ - ### $ 50,053 $ 20,021 $ (30,032)
43 Santa Cruz Foothill - DeAnza Comm College Dist 11/12-1 Err:520 $ 42,256 $ 31,692 $ 10,564 $ - ### $ - 2
44 Santa Cruz Foothill - DeAnza Comm College Dist 10/11-2 2013-Q1 $ - $ - ### $ 51,725 $ 20,690 $ (31,035)
45 Santa Cruz Foothill - DeAnza Comm College Dist 11/12-2 Err:520 $ 58,441 $ 23,376 $ 35,065 $ - ### $ -
46 Santa Cruz Foothill - DeAnza Comm. College District 10/11-3 Err:520 $ 62,945 $ 25,178 $ 37,767 $ - ### $ -
47 Santa Cruz Foothill - DeAnza Comm College Dist 11/12-3 Err:520 $ 50,515 $ 20,206 $ 30,309 $ - ### $ -
48 Santa Cruz Foothill - DeAnza Comm College Dist 10/11-4 Err:520 $ 56,637 $ 22,655 $ 33,982 $ - ### $ -
49 Santa Cruz Foothill - DeAnza Comm College Dist 11/12-4 Err:520 $ 51,522 $ 20,609 $ 30,913 $ - ### $ -
50 Foothill - DeAnza Comm College Dist Total* $ 322,316 $ 143,716 $ 178,600 $ 101,778 $ 40,711 $ (61,067) $ 82,649 3.23% $ 30,341 $ 52,308 $ 709
51 Santa Cruz Gilroy USD 10/11-1 2012-Q4 $ - $ - ### $ - ### $ - 2
52 Santa Cruz Gilroy USD 10/11-2 Err:520 $ - $ - $ - $ - ### $ -
53 Santa Cruz Gilroy USD 11/12-4 Err:520 $ - $ - $ - $ - ### $ -
54 Gilroy USD Total $ - $ - $ - $ - $ - $ - $ -
55 Santa Cruz Hollister ESD 11/12-2 Err:520 $ 49,967 $ 37,475 $ 12,492 $ - ### $ - 2
56 Santa Cruz Hollister ESD 11/12-3 Err:520 $ 38,801 $ 29,101 $ 9,700 $ - ### $ - 2
57 Santa Cruz Hollister ESD 11/12-4 Err:520 $ 40,626 $ 30,470 $ 10,156 $ - ### $ - 2
58 Hollister ESD Total $ 129,394 $ 97,046 $ 32,348 $ - $ - $ - $ 97,046 3.79% $ 35,627 $ 61,419 $ 833
59 Santa Cruz Milpitas USD 11/12-2 Err:520 $ 73,954 $ 29,582 $ 44,372 $ - ### $ -
60 Santa Cruz Milpitas USD 11/12-3 Err:520 $ 38,341 $ 28,756 $ 9,585 $ - ### $ - 2
61 Santa Cruz Milpitas USD 10/11-4 Err:520 $ 25,263 $ 25,000 $ 263 $ - ### $ - 2
62 Milpitas USD Total $ 137,558 $ 83,338 $ 54,220 $ - $ - $ - $ 83,338 3.25% $ 30,594 $ 52,744 $ 715
63 Santa Cruz Monterey COE - Home Charter 10/11-3 Err:520 $ 37,152 $ 27,864 $ 9,288 $ - ### $ - 2
64 Santa Cruz Monterey COE - Home Charter 11/12-3 Err:520 $ 30,702 $ 25,000 $ 5,702 $ - ### $ - 2
65 Santa Cruz Monterey COE - Home Charter 11/12-4 Err:520 $ 25,655 $ 25,000 $ 655 $ - ### $ - 2
66 Monterey COE - Home Charter Total $ 93,509 $ 77,864 $ 15,645 $ - $ - $ - $ 77,864 3.04% $ 28,585 $ 49,279 $ 668
67 Santa Cruz Monterey COE - Sp Ed 10/11-1 2012-Q4 $ - $ - ### $ 48,772 $ 36,579 $ (12,193) 2
68 Santa Cruz Monterey COE - Sp Ed 11/12-1 Err:520 $ 45,853 $ 34,390 $ 11,463 $ - ### $ - 2
69 Santa Cruz Monterey COE - Sp Ed 10/11-2 2013-Q1 $ - $ - ### $ 48,366 $ 36,275 $ (12,091) 2
70 Santa Cruz Monterey COE - Sp Ed 11/12-2 Err:520 $ 50,893 $ 20,357 $ 30,536 $ - ### $ -
71 Santa Cruz Monterey COE - Sp Ed 10/11-3 2013-Q2 $ - $ - ### $ 72,523 $ 29,009 $ (43,514)
72 Santa Cruz Monterey COE - Sp Ed 11/12-3 Err:520 $ 49,160 $ 36,870 $ 12,290 $ - ### $ - 2
73 Santa Cruz Monterey COE - Sp Ed 10/11-4 2013-Q3 $ - $ - ### $ 51,901 $ 20,760 $ (31,141) 2
74 Santa Cruz Monterey COE - Sp Ed 11/12-4 Err:520 $ 44,756 $ 33,567 $ 11,189 $ - ### $ - 2
75 Monterey COE - Sp Ed Total $ 190,662 $ 125,184 $ 65,478 $ 221,562 $ 122,623 $ (98,939) $ 26,245 1.02% $ 9,635 $ 16,610 $ 225
76 Santa Cruz Monterey COE- Alt Ed. 10/11-1 2012-Q4 $ - $ - ### $ 38,659 $ 27,061 $ (11,598)
77 Santa Cruz Monterey COE - Alt Ed 10/11-3 Err:520 $ 43,312 $ 30,318 $ 12,994 $ - ### $ -
78 Santa Cruz Monterey COE- Alt Ed. 10/11-2 2013-Q1 $ - $ - ### $ 31,916 $ 22,341 $ (9,575)
79 Santa Cruz Monterey COE - Alt Ed. 11/12-1 Err:520 $ 32,415 $ 22,691 $ 9,724 $ - ### $ -
80 Santa Cruz Monterey COE - Alt. Ed. 10/11-4 Err:520 $ 29,485 $ 20,640 $ 8,845 $ - ### $ -
81 Santa Cruz Monterey COE- Alt Ed. 11/12-3 Err:520 $ 36,722 $ 25,705 $ 11,017 $ - ### $ -
82 Santa Cruz Monterey COE- Alt Ed. 11/12-4 Err:520 $ 33,712 $ 23,598 $ 10,114 $ - ### $ -
83 Monterey COE- Alt Ed. Total $ 175,646 $ 122,952 $ 52,694 $ 70,575 $ 49,402 $ (21,173) $ 101,779 3.97% $ 37,364 $ 64,415 $ 874
84 Santa Cruz Monterey Peninsula USD 11/12-1 Err:520 $ 39,635 $ 29,726 $ 9,909 $ - ### $ - 2
85 Santa Cruz Monterey Peninsula USD 11/12-2 Err:520 $ 36,116 $ 27,087 $ 9,029 $ - ### $ - 2
86 Santa Cruz Monterey Peninsula USD 11/12-3 Err:520 $ 34,291 $ 25,718 $ 8,573 $ - ### $ - 2
87 Santa Cruz Monterey Peninsula USD 09/10-4 2012-Q3 $ - $ - ### $ 41,343 $ 31,007 $ (10,336) 2
88 Santa Cruz Monterey Peninsula USD 10/11-4 Err:520 $ 26,721 $ 25,000 $ 1,721 $ - ### $ - 2
89 Monterey Peninsula USD Total $ 136,763 $ 107,531 $ 29,232 $ 41,343 $ 31,007 $ (10,336) $ 97,195 3.79% $ 35,681 $ 61,514 $ 834
90 Santa Cruz N. Monterey County USD 10/11-1 2012-Q4 $ - $ - ### $ 57,681 $ 23,072 $ (34,609) 2
91 Santa Cruz N. Monterey County USD 11/12-1 Err:520 $ 45,550 $ 34,163 $ 11,387 $ - ### $ - 2
92 Santa Cruz N. Monterey County USD 10/11-2 2013-Q1 $ - $ - ### $ 52,913 $ 21,165 $ (31,748) 2
93 Santa Cruz N. Monterey County USD 11/12-2 Err:520 $ 39,883 $ 29,912 $ 9,971 $ - ### $ - 2
94 Santa Cruz N. Monterey County USD 11/12-3 Err:520 $ 51,215 $ 20,486 $ 30,729 $ - ### $ -
95 Santa Cruz N. Monterey County USD 10/11-4 Err:520 $ 88,118 $ 35,247 $ 52,871 $ - ### $ -
96 Santa Cruz N. Monterey County USD 11/12-4 Err:520 $ 55,380 $ 22,152 $ 33,228 $ - ### $ -
97 Santa Cruz N. Monterey County USD 10/11-3 Err:520 $ 87,642 $ 35,057 $ 52,585 $ - ### $ -
98 N. Monterey County USD Total $ 367,788 $ 177,017 $ 190,771 $ 110,594 $ 44,237 $ (66,357) $ 110,660 4.32% $ 40,625 $ 70,035 $ 950
99 Santa Cruz Oak Grove SD 11/12-1 Err:520 $ 27,555 $ 25,000 $ 2,555 $ - ### $ - 2
100 Santa Cruz Oak Grove SD 10/11-2 2013-Q1 $ - $ - ### $ 71,542 $ 28,617 $ (42,925)
101 Santa Cruz Oak Grove SD 11/12-2 Err:520 $ 64,439 $ 25,776 $ 38,663 $ - ### $ -
102 Santa Cruz Oak Grove SD 10/11-3 2013-Q2 $ - $ - ### $ 52,329 $ 20,932 $ (31,397)
103 Santa Cruz Oak Grove SD 11/12-3 Err:520 $ 73,044 $ 29,218 $ 43,826 $ - ### $ -
104 Santa Cruz Oak Grove SD 10/11-4 2013-Q3 $ - $ - ### $ 70,752 $ 28,301 $ (42,451)
105 Santa Cruz Oak Grove SD 12/13-1 Err:520 $ 17,221 $ 15,499 $ 1,722
106 Santa Cruz Oak Grove SD 11/12-4C-1 Err:520 $ 70,867 $ 28,347 $ 42,520 $ - ### $ -
107 Oak Grove SD Total $ 253,126 $ 123,840 $ 129,286 $ 194,623 $ 77,850 $ (116,773) $ 7,067 0.28% $ 2,594 $ 4,473 $ 61
108 Santa Cruz Pacific Grove USD 11/12-3 Err:520 $ 34,258 $ 25,694 $ 8,564 $ - ### $ - 2
109 Pacific Grove USD Total $ 34,258 $ 25,694 $ 8,564 $ - $ - $ - $ 25,694 1.00% $ 9,433 $ 16,261 $ 221
110 Santa Cruz Salinas City ESD 10/11-1 2012-Q4 $ - $ - ### $ 36,173 $ 27,130 $ (9,043) 2
111 Santa Cruz Salinas City ESD 11/12-1 Err:520 $ 41,192 $ 30,894 $ 10,298 $ - ### $ - 2
112 Santa Cruz Salinas City ESD 10/11-2 Err:520 $ 47,459 $ 35,594 $ 11,865 $ - ### $ - 2
A B C D E F G H I J K L M N O P Q R S T U

Total amount
2 Period of Amount to be recouped withheld (FFY
Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata Amount to release to 2013 and CUs in Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent claiming unit Red) or 2) Salinas Union HSD
113 Santa Cruz Salinas City ESD 11/12-2 Err:520 $ 33,582 $ 25,187 $ 8,395 $ - ### $ - 2
114 Santa Cruz Salinas City ESD 10/11-3 Err:520 $ 52,247 $ 20,899 $ 31,348 $ - ### $ -
115 Santa Cruz Salinas City ESD 11/12-3 Err:520 $ 53,451 $ 21,380 $ 32,071 $ - ### $ -
116 Santa Cruz Salinas City ESD 09/10-4 2012-Q3 $ - $ - ### $ 38,140 $ 28,605 $ (9,535) 2
117 Santa Cruz Salinas City ESD 10/11-4 Err:520 $ 52,475 $ 20,990 $ 31,485 $ - ### $ -
118 Santa Cruz Salinas City ESD 11/12-4 Err:520 $ 49,759 $ 37,319 $ 12,440 $ - ### $ - 2
119 Salinas City ESD Total $ 330,165 $ 192,263 $ 137,902 $ 74,313 $ 55,735 $ (18,578) $ 173,685 6.78% $ 63,762 $ 109,923 $ 1,491
120 Santa Cruz Salinas Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 28,906 $ 25,000 $ (3,906) 2
121 Santa Cruz Salinas Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 61,536 $ 24,614 $ (36,922)
122 Santa Cruz Salinas Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 77,529 $ 31,012 $ (46,517)
123 Santa Cruz Salinas Union HSD 12/13-1 Err:520 $ 2,139 $ 1,925 $ 214
124 Santa Cruz Salinas Union HSD 12/13-2 Err:520 $ 2,665 $ 2,399 $ 266
125 Santa Cruz Salinas Union HSD 12/13-3 Err:520 $ 20,606 $ 18,545 $ 2,061
126 Santa Cruz Salinas Union HSD 12/13-4 Err:520 $ 7,056 $ 6,350 $ 706
127 Santa Cruz Salinas Union HSD 13/14-1 Err:520 $ 8,287 $ 7,458 $ 829
128 Santa Cruz Salinas Union HSD 13/14-2 Err:520 $ 15,250 $ 13,725 $ 1,525
129 Santa Cruz Salinas Union HSD 13/14-3 Err:520 $ 18,400 $ 16,560 $ 1,840
130 Santa Cruz Salinas Union HSD 13/14-4 Err:520 $ 11,052 $ 9,947 $ 1,105
131 Santa Cruz Salinas Union HSD 10/11-4 2013-Q3 $ - $ - ### $ 46,250 $ 34,688 $ (11,562) 2
132 Salinas Union HSD Total $ 85,455.00 $ 76,909.00 $ 8,546.00 $ 214,221 $ 115,314 $ (98,907) $ (21,998) 100%
133 Santa Cruz San Jose City College 10/11-1 2012-Q4 $ - $ - ### $ 30,170 $ 21,119 $ (9,051)
134 Santa Cruz San Jose City College 09/10-4 2012-Q3 $ - $ - ### $ 26,058 $ 18,241 $ (7,817)
135 Santa Cruz San Jose City College 10/11-4 Err:520 $ 26,430 $ 18,501 $ 7,929 $ - ### $ -
136 San Jose City College Total $ 26,430.00 $ 18,501.00 $ 7,929.00 $ 56,228 $ 39,360 $ (16,868) $ 1,633 0.06% $ 599 $ 1,034 $ 14
137 Santa Cruz Santa Clara COE 10/11-1 2012-Q4 $ - $ - ### $ 232,627 $ 93,051 $ (139,576)
138 Santa Cruz Santa Clara COE 11/12-1 Err:520 $ 197,738 $ 79,095 $ 118,643 $ - ### $ -
139 Santa Cruz Santa Clara COE 10/11-2 Err:520 $ 301,195 $ 120,478 $ 180,717 $ - ### $ -
140 Santa Cruz Santa Clara COE 11/12-2 Err:520 $ 239,398 $ 95,759 $ 143,639 $ - ### $ -
141 Santa Cruz Santa Clara COE 10/11-3 Err:520 $ 204,811 $ 81,924 $ 122,887 $ - ### $ -
142 Santa Cruz Santa Clara COE 11/12-3 Err:520 $ 226,334 $ 90,534 $ 135,800 $ - ### $ -
143 Santa Cruz Santa Clara COE 09/10-4 2012-Q3 $ - $ - ### $ 203,899 $ 81,560 $ (122,339)
144 Santa Cruz Santa Clara COE 10/11-4 Err:520 $ 241,806 $ 96,722 $ 145,084 $ - ### $ -
145 Santa Cruz Santa Clara COE 11/12-4 Err:520 $ 242,709 $ 97,084 $ 145,625 $ - ### $ -
146 Santa Clara COE Total $ 1,653,991 $ 661,596 $ 992,395 $ 436,526 $ 174,611 $ (261,915) $ 399,681 15.60% $ 146,728 $ 252,953 $ 3,431
147 Santa Cruz Santa Clara USD 10/11-1 2012-Q4 $ - $ - ### $ 31,360 $ 25,000 $ (6,360) 2
148 Santa Cruz Santa Clara USD 11/12-1 Err:520 $ 85,478 $ 34,191 $ 51,287 $ - ### $ -
149 Santa Cruz Santa Clara USD 10/11-2 2013-Q1 $ - $ - ### $ 37,499 $ 28,124 $ (9,375) 2
150 Santa Cruz Santa Clara USD 11/12-2 Err:520 $ 113,460 $ 45,384 $ 68,076 $ - ### $ -
151 Santa Cruz Santa Clara USD 10/11-3 Err:520 $ 44,228 $ 33,171 $ 11,057 $ - ### $ - 2
152 Santa Cruz Santa Clara USD 11/12-3 Err:520 $ 100,119 $ 40,048 $ 60,071 $ - ### $ -
153 Santa Cruz Santa Clara USD 09/10-4 2012-Q3 $ - $ - ### $ 33,980 $ 25,485 $ (8,495) 2
154 Santa Cruz Santa Clara USD 10/11-4 Err:520 $ 34,323 $ 25,742 $ 8,581 $ - ### $ - 2
155 Santa Cruz Santa Clara USD 11/12-4 Err:520 $ 103,504 $ 41,402 $ 62,102 $ - ### $ -
156 Santa Clara USD Total $ 481,112 $ 219,938 $ 261,174 $ 102,839 $ 78,609 $ (24,230) $ 195,708 7.64% $ 71,847 $ 123,861 $ 1,680
157 Santa Cruz Santa Cruz City Schools 11/12-2 Err:520 $ 38,409 $ 28,807 $ 9,602 $ - ### $ - 2
158 Santa Cruz Santa Cruz City Schools 11/12-3 Err:520 $ 45,019 $ 33,764 $ 11,255 $ - ### $ - 2
159 Santa Cruz Santa Cruz City Schools 11/12-4 Err:520 $ 46,051 $ 34,538 $ 11,513 $ - ### $ - 2
160 Santa Cruz City Schools Total* $ 129,479 $ 97,109 $ 32,370 $ - $ - $ - $ 97,109 3.79% $ 35,650 $ 61,459 $ 834
161 Santa Cruz Santa Cruz City Schools - Branciforte Sm. Sch. 10/11-3 Err:520 $ 33,728 $ 25,296 $ 8,432 $ - ### $ - 2
Santa Cruz City Schools- Branciforte Small
162
Santa Cruz Schools 11/12-3 Err:520 $ 29,179 $ 25,000 $ 4,179 $ - ### $ - 2
163 Santa Cruz Santa Cruz City Schools-Branciforte Small Sch 10/11-4 Err:520 $ 28,390 $ 25,000 $ 3,390 $ - ### $ - 2
164 Santa Cruz City Schools - Branciforte Sm. Sch. Total* $ 91,297 $ 75,296 $ 16,001 $ - $ - $ - $ 75,296 2.94% $ 27,642 $ 47,654 $ 646
165 Santa Cruz Santa Cruz COE - Alt Ed 10/11-1 2012-Q4 $ - $ - ### $ 60,547 $ 24,219 $ (36,328)
166 Santa Cruz Santa Cruz COE - Alt Ed 11/12-1 Err:520 $ 59,510 $ 23,804 $ 35,706 $ - ### $ -
167 Santa Cruz Santa Cruz COE - Alt Ed 10/11-2 Err:520 $ 81,542 $ 32,617 $ 48,925 $ - ### $ -
168 Santa Cruz Santa Cruz COE - Alt Ed 11/12-2 Err:520 $ 67,081 $ 26,832 $ 40,249 $ - ### $ -
169 Santa Cruz Santa Cruz COE - Alt Ed 10/11-3 Err:520 $ 118,855 $ 47,542 $ 71,313 $ - ### $ -
170 Santa Cruz Santa Cruz COE - Alt Ed 11/12-3 Err:520 $ 103,218 $ 41,287 $ 61,931 $ - ### $ -
171 Santa Cruz Santa Cruz COE - Alt Ed 10/11-4 Err:520 $ 107,162 $ 42,865 $ 64,297 $ - ### $ -
172 Santa Cruz Santa Cruz COE - Alt Ed 11/12-4 Err:520 $ 84,233 $ 33,693 $ 50,540 $ - ### $ -
173 Santa Cruz COE - Alt Ed Total $ 621,601 $ 248,640 $ 372,961 $ 60,547 $ 24,219 $ (36,328) $ 212,312 8.29% $ 77,942 $ 134,370 $ 1,823
174 Santa Cruz Santa Cruz COE - Sp Ed 10/11-1 2012-Q4 $ - $ - ### $ 31,318 $ 25,000 $ (6,318) 2
175 Santa Cruz Santa Cruz COE - Sp Ed 11/12-1 Err:520 $ 32,892 $ 25,000 $ 7,892 $ - ### $ - 2
176 Santa Cruz Santa Cruz COE - Sp Ed 10/11-2 2013-Q1 $ - $ - ### $ 43,289 $ 32,467 $ (10,822) 2
177 Santa Cruz Santa Cruz COE - Sp Ed 11/12-2 Err:520 $ 40,105 $ 30,079 $ 10,026 $ - ### $ - 2
178 Santa Cruz Santa Cruz COE - Sp Ed 10/11-3 Err:520 $ 50,949 $ 20,380 $ 30,569 $ - ### $ -
179 Santa Cruz Santa Cruz COE - Sp Ed 11/12-3 Err:520 $ 52,110 $ 20,844 $ 31,266 $ - ### $ -
180 Santa Cruz Santa Cruz COE - Sp Ed 10/11-4 Err:520 $ 36,458 $ 27,344 $ 9,114 $ - ### $ - 2
181 Santa Cruz Santa Cruz COE - Sp Ed 11/12-4 Err:520 $ 42,797 $ 32,098 $ 10,699 $ - ### $ - 2
182 Santa Cruz COE - Sp Ed Total $ 255,311 $ 155,745 $ 99,566 $ 74,607 $ 57,467 $ (17,140) $ 138,605 5.41% $ 50,884 $ 87,721 $ 1,190
183 Santa Cruz Santa Rita UESD 11/12-3 Err:520 $ 50,902 $ 17,816 $ 33,086 $ - ### $ -
184 Santa Cruz Santa Rita UESD 11/12-4 Err:520 $ 26,872 $ 18,810 $ 8,062 $ - ### $ -
185 Santa Rita UESD Total $ 77,774 $ 36,626 $ 41,148 $ - $ - $ - $ 36,626 1.43% $ 13,446 $ 23,180 $ 314
186 Santa Cruz Soledad USD 11/12-1 Err:520 $ 26,966 $ 25,000 $ 1,966 $ - ### $ - 2
187 Santa Cruz Soledad USD 11/12-2 Err:520 $ 39,336 $ 29,502 $ 9,834 $ - ### $ - 2
188 Santa Cruz Soledad USD 10/11-3 Err:520 $ 32,010 $ 25,000 $ 7,010 $ - ### $ - 2
189 Santa Cruz Soledad USD 11/12-3 Err:520 $ 59,552 $ 23,821 $ 35,731 $ - ### $ -
190 Santa Cruz Soledad USD 11/12-4 Err:520 $ 57,953 $ 23,181 $ 34,772 $ - ### $ -
191 Soledad USD Total $ 215,817 $ 126,504 $ 89,313 $ - $ - $ - $ 126,504 4.94% $ 46,441 $ 80,063 $ 1,086
192 Santa Cruz Sunnyvale SD 10/11-2 2013-Q1 $ - $ - ### $ 31,758 $ 25,000 $ (6,758) 2
193 Santa Cruz Sunnyvale SD 11/12-2 Err:520 $ 36,862 $ 27,647 $ 9,215 $ - ### $ - 2
194 Santa Cruz Sunnyvale SD 10/11-4 2013-Q3 $ - $ - ### $ 28,890 $ 25,000 $ (3,890) 2
195 Sunnyvale SD Total $ 36,862.00 $ 27,647.00 $ 9,215.00 $ 60,648 $ 50,000 $ (10,648) $ 16,999 0.66% $ 6,241 $ 10,758 $ 146
196 Santa Cruz Pajaro Valley USD 11/12-1 Err:520 $ 56,678 $ 22,671 $ 34,007 $ - ### $ -
197 Santa Cruz Pajaro Valley USD 11/12-2 Err:520 $ 33,072 $ 25,000 $ 8,072 $ - ### $ - 2
198 Santa Cruz Pajaro Valley USD 11/12-3 Err:520 $ 53,929 $ 21,572 $ 32,357 $ - ### $ -
199 Santa Cruz Pajaro Valley USD 10/11-1 2012-Q4 $ - $ - ### $ 90,995 $ 36,398 $ (54,597)
200 Santa Cruz Pajaro Valley USD 10/11-2 2013-Q1 $ - $ - ### $ 91,944 $ 36,778 $ (55,166)
201 Santa Cruz Pajaro Valley USD 10/11-3 Err:520 $ 105,194 $ 42,078 $ 63,116 $ - ### $ -
202 Santa Cruz Pajaro Valley USD 10/11-4 Err:520 $ 62,494 $ 24,998 $ 37,496 $ - ### $ -
203 Santa Cruz Pajaro Valley USD 11/12-4 Err:520 $ 27,562 $ 25,000 $ 2,562 $ - ### $ - 2
204 Pajaro Valley USD Total $ 338,929 $ 161,319 $ 177,610 $ 182,939 $ 73,176 $ (109,763) $ 51,556 2.01% $ 18,927 $ 32,629 $ 443
205 Grand Total Santa Cruz LEC $ 7,715,845 $ 3,925,240 $ 3,790,605 $ 2,759,886 $ 1,375,223 $ (1,384,663) $ 2,540,577 100% $ 940,752 $ 1,621,823 $ 21,998
206 The sum of Column N equals the sum of "Column K" (Net Total) minus
207 the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
208 Column A County - Reporting LEC/LGA
209 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12 Pro-Rata Table
210 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Full check amount Check Total $ 940,751 <-- Enter check total here
211 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed has not been received Sum of Net Green $ 2,562,575
212 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment Sum of Net Red $ (21,998)
213 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
214 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
215 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
216 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
217 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
218 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
219 The last subtotal amount is the final amount due to/from the LEC/LGA
A B C D E F G H I J K L M N O P Q R S T U

Total amount
2 Period of Amount to be recouped withheld (FFY
Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata Amount to release to 2013 and CUs in Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent claiming unit Red) or 2) Salinas Union HSD
220 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
221 Column N The sum of Column N equals the sum of "Column K" (Net Total) minus the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
222 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
223 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
224 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
225

226 Released
Claiming Unit Invoice on placeholder to be paid 100%
227

228 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
229 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
230

231 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
232 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
233 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
234 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
235

236 Claiming units no longer participating (5% reduction)


237
238 12/13 claims
239 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Solano LGA Fairfield - Suisun USD - Healthy Start 11/12-2 Err:520 $ 25,210 $ 25,000 $ 210 $ - ### $ - 2 2777
3 Fairfield - Suisun USD - Healthy Start Total $ 25,210 $ 25,000 $ 210 $ - $ - $ - $ 25,000
4 Solano LGA Solano County SELPA 10/11-1 2012-Q4 $ - $ - ### $ 25,805 $ 25,000 $ (805) 2
5 Solano LGA Solano County SELPA 11/12-1 Err:520 $ 34,871 $ 26,153 $ 8,718 $ - ### $ - 2 2002
6 Solano LGA Solano County SELPA 10/11-2 2013-Q1 $ - $ - ### $ 39,529 $ 29,647 $ (9,882) 2
7 Solano LGA Solano County SELPA 11/12-2 Err:520 $ 39,137 $ 29,353 $ 9,784 $ - ### $ - 2 2778
8 Solano LGA Solano County SELPA 11/12-3 Err:520 $ 46,762 $ 35,072 $ 11,690 $ - ### $ - 2 3583
9 Solano LGA Solano County SELPA 10/11-4 Err:520 $ 40,130 $ 30,098 $ 10,032 $ - ### $ - 2 1341
10 Solano LGA Solano County SELPA 11/12-4 Err:520 $ 47,743 $ 35,807 $ 11,936 $ - ### $ - 2 4354
11 Solano LGA Solano County SELPA 10/11-3 Err:520 $ 35,116 $ 26,337 $ 8,779 $ - ### $ - 2 871
12 Solano County SELPA Total $ 243,759 $ 182,820 $ 60,939 $ 65,334 $ 54,647 $ (10,687) $ 172,133
13 Solano LGA Vallejo City USD 10/11-1 2012-Q4 $ - $ - ### $ 59,758 $ 23,903 $ (35,855)
14 Solano LGA Vallejo City USD 11/12-1 Err:520 $ 30,591 $ 25,000 $ 5,591 $ - ### $ - 2 2003
15 Solano LGA Vallejo City USD 10/11-2 Err:520 $ 47,341 $ 35,506 $ 11,835 $ - ### $ - 2 623
16 Solano LGA Vallejo City USD 11/12-2 Err:520 $ 47,603 $ 35,702 $ 11,901 $ - ### $ - 2 2779
17 Solano LGA Vallejo City USD 10/11-3 Err:520 $ 41,148 $ 30,861 $ 10,287 $ - ### $ - 2 872
18 Solano LGA Vallejo City USD 11/12-3 Err:520 $ 31,795 $ 25,000 $ 6,795 $ - ### $ - 2 3584
19 Solano LGA Vallejo City USD 10/11-4 Err:520 $ 45,593 $ 34,195 $ 11,398 $ - ### $ - 2 1342
20 Solano LGA Vallejo City USD 11/12-4 Err:520 $ 36,462 $ 27,347 $ 9,115 $ - ### $ - 2 4355
21 Vallejo City USD Total $ 280,533 $ 213,611 $ 66,922 $ 59,758 $ 23,903 $ (35,855) $ 177,756
22 Grand Total Solano LGA $ 549,502 $ 421,431 $ 128,071 $ 125,092 $ 78,550 $ (46,542) $ 374,889
23
24
25 Column A County - Reporting LEC/LGA
26 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
27 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
28 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
29 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
30 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
31 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
32 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
33 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
34 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
35 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
36 The last subtotal amount is the final amount due to/from the LEC/LGA
37 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
38

39 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
40 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
41 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
42

43 Released Claiming Unit Invoice on placeholder to be paid 100%


44

45 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
46 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
47

48 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
49 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
50 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
51 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
52

53 Claiming units no longer participating (5% reduction)


54
55 12/13 claims
56 13/14 claims
A B C D E F G H I J K L M
Period of Submitted for Amount to be recouped
1 Service Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Sonoma Bellevue Union SD 10/11-2 2013-Q1 $ - $ - ### $ 29,749 $ 25,000 $ (4,749) 2
3 Sonoma Bellevue Union SD 12/13-1 Err:520 $ 15,722 $ 14,150 $ 1,572 5126
4 Bellevue Union SD Total $ 15,722 $ 14,150 $ 1,572 $ 29,749 $ 25,000 $ (4,749) $ 9,401
5 Sonoma Cotati-Rohnert Park USD 10/11-1 2012-Q4 $ - $ - ### $ 27,608 $ 25,000 $ (2,608) 2
6 Sonoma Cotati-Rohnert Park USD 10/11-2 2013-Q1 $ - $ - ### $ 29,333 $ 25,000 $ (4,333) 2
7 Sonoma Cotati-Rohnert Park USD 11/12-2 Err:520 $ 61,388 $ 24,555 $ 36,833 $ - ### $ - 2788
8 Sonoma Cotati-Rohnert Park USD 11/12-3 Err:520 $ 56,483 $ 22,593 $ 33,890 $ - ### $ - 3593
9 Sonoma Cotati-Rohnert Park USD 11/12-4 Err:520 $ 44,864 $ 33,648 $ 11,216 $ - ### $ - 2 4364
10 Cotati-Rohnert Park USD Total $ 162,735 $ 80,796 $ 81,939 $ 56,941 $ 50,000 $ (6,941) $ 73,855
11 Sonoma Del Norte County USD 10/11-2 2013-Q1 $ - $ - ### $ 28,852 $ 25,000 $ (3,852) 2
12 Sonoma Del Norte County USD 12/13-1 Err:520 $ 1,277 $ 1,149 $ 128 5133
13 Sonoma Del Norte County USD 12/13-2 Err:520 $ 3,200 $ 2,880 $ 320 5934
14 Sonoma Del Norte County USD 12/13-3 Err:520 $ 2,246 $ 2,021 $ 225 6705
15 Sonoma Del Norte County USD 12/13-4 Err:520 $ 2,986 $ 2,687 $ 299
16 Sonoma Del Norte County USD 09/10-4 2012-Q3 $ - $ - ### $ 29,527 $ 25,000 $ (4,527) 2
17 Del Norte County USD Total $ 9,709.00 $ 8,737.00 $ 972.00 $ 58,379 $ 50,000 $ (8,379) $ 358
18 Sonoma Fort Bragg SD 10/11-1 2012-Q4 $ - $ - ### $ 33,761 $ 25,321 $ (8,440) 1
19 Sonoma Fort Bragg SD 11/12-1 Err:520 $ 28,679 $ 25,000 $ 3,679 $ - ### $ - 2 2014
20 Sonoma Fort Bragg SD 10/11-2 2013-Q1 $ - $ - ### $ 48,902 $ 36,677 $ (12,225) 1
21 Sonoma Fort Bragg SD 11/12-2 Err:520 $ 38,659 $ 28,994 $ 9,665 $ - ### $ - 1 2792
22 Sonoma Fort Bragg SD 10/11-3 2013-Q2 $ - $ - ### $ 38,079 $ 28,559 $ (9,520) 1
23 Sonoma Fort Bragg SD 11/12-3 Err:520 $ 50,889 $ 20,356 $ 30,533 $ - ### $ - 3597
24 Sonoma Fort Bragg SD 10/11-4 2013-Q3 $ - $ - ### $ 41,522 $ 31,142 $ (10,380) 1
25 Sonoma Fort Bragg SD 11/12-4 Err:520 $ 55,665 $ 22,266 $ 33,399 $ - ### $ - 4368
26 Fort Bragg SD Total $ 173,892 $ 96,616 $ 77,276 $ 162,264 $ 121,699 $ (40,565) $ 56,051
27 Sonoma Fortuna HSD 10/11-2 2013-Q1 $ - $ - ### $ 35,711 $ 26,783 $ (8,928) 2
28 Sonoma Fortuna HSD 09/10-4 2012-Q3 $ - $ - ### $ 31,511 $ 25,000 $ (6,511) 2
29 Sonoma Fortuna HSD 10/11-4 Err:520 $ 26,718 $ 25,000 $ 1,718 $ - ### $ - 2 1353
30 Fortuna HSD Total $ 26,718 $ 25,000 $ 1,718 $ 67,222 $ 51,783 $ (15,439) $ 9,561
31 Sonoma Humboldt COE 10/11-1 2012-Q4 $ - $ - ### $ 46,459 $ 34,844 $ (11,615) 1
32 Sonoma Humboldt COE 11/12-1 Err:520 $ 57,045 $ 22,818 $ 34,227 $ - ### $ - 2020
33 Sonoma Humboldt COE 10/11-2 2013-Q1 $ - $ - ### $ 72,647 $ 29,059 $ (43,588)
34 Sonoma Humboldt COE 11/12-2 Err:520 $ 93,425 $ 37,370 $ 56,055 $ - ### $ - 2798
35 Sonoma Humboldt COE 10/11-3 Err:520 $ 68,812 $ 27,525 $ 41,287 $ - ### $ - 886
36 Sonoma Humboldt COE 11/12-3 Err:520 $ 96,610 $ 38,644 $ 57,966 $ - ### $ - 3603
37 Sonoma Humboldt COE 09/10-4 2012-Q3 $ - $ - ### $ 87,460 $ 34,984 $ (52,476)
38 Sonoma Humboldt COE 10/11-4 Err:520 $ 69,811 $ 27,924 $ 41,887 $ - ### $ - 1357
39 Sonoma Humboldt COE 11/12-4 Err:520 $ 85,146 $ 34,058 $ 51,088 $ - ### $ - 4374
40 Humboldt COE Total $ 470,849 $ 188,339 $ 282,510 $ 206,566 $ 98,887 $ (107,679) $ 80,660
41 Sonoma Kelseyville USD 10/11-3 Err:520 $ 27,666 $ 25,000 $ 2,666 $ - ### $ - 2 887
42 Kelseyville USD Total $ 27,666 $ 25,000 $ 2,666 $ - $ - $ - $ 25,000
43 Sonoma Klamath-Trinity Joint USD 11/12-1 Err:520 $ 26,108 $ 25,000 $ 1,108 $ - ### $ - 2 2023
44 Sonoma Klamath-Trinity Joint USD 10/11-2 2013-Q1 $ - $ - ### $ 34,183 $ 25,637 $ (8,546) 2
45 Sonoma Klamath-Trinity Joint USD 11/12-2 Err:520 $ 46,453 $ 34,840 $ 11,613 $ - ### $ - 2 2801
46 Sonoma Klamath-Trinity Joint USD 10/11-3 Err:520 $ 37,005 $ 27,754 $ 9,251 $ - ### $ - 2 888
47 Sonoma Klamath-Trinity Joint USD 11/12-3 Err:520 $ 34,325 $ 25,744 $ 8,581 $ - ### $ - 2 3606
48 Sonoma Klamath-Trinity Joint USD 11/12-4 Err:520 $ 47,222 $ 35,417 $ 11,805 $ - ### $ - 2 4377
49 Klamath-Trinity Joint USD Total $ 191,113 $ 148,755 $ 42,358 $ 34,183 $ 25,637 $ (8,546) $ 140,209
50 Sonoma Konocti USD 10/11-2 2013-Q1 $ - $ - ### $ 31,943 $ 25,000 $ (6,943) 2
51 Sonoma Konocti USD 10/11-3 Err:520 $ 26,274 $ 25,000 $ 1,274 $ - ### $ - 2 889
52 Sonoma Konocti USD 10/11-4 Err:520 $ 27,933 $ 25,000 $ 2,933 $ - ### $ - 2 1360
53 Sonoma Konocti USD 11/12-4 Err:520 $ 30,316 $ 25,000 $ 5,316 $ - ### $ - 2 4378
54 Konocti USD Total $ 84,523 $ 75,000 $ 9,523 $ 31,943 $ 25,000 $ (6,943) $ 68,057
55 Sonoma MCOE Arena Union and High 11/12-3 Err:520 $ 27,201 $ 25,000 $ 2,201 $ - ### $ - 2 3613
56 Sonoma MCOE Arena Union and High 10/11-4 Err:520 $ 25,152 $ 25,000 $ 152 $ - ### $ - 2 1366
57 Sonoma MCOE Arena Union and High 11/12-4 Err:520 $ 28,690 $ 25,000 $ 3,690 $ - ### $ - 2 4385
58 MCOE Arena Union and High Total $ 81,043 $ 75,000 $ 6,043 $ - $ - $ - $ 75,000
59 Sonoma MCOE
MCOE Arena
ArenaUnion
UnionElementary andand
Elementary High 11/12-2 Err:520 $ 27,855 $ 25,000 $ 2,855 $ - ### $ - 2 2809
60 High Total $ 27,855 $ 25,000 $ 2,855 $ - $ - $ - $ 25,000
61 Sonoma MCOE Laytonville 10/11-1 2012-Q4 $ - $ - ### $ 27,677 $ 25,000 $ (2,677) 2
62 Sonoma MCOE Laytonville 11/12-1 Err:520 $ 32,049 $ 25,000 $ 7,049 $ - ### $ - 2 2033
63 Sonoma MCOE Laytonville 10/11-2 2013-Q1 $ - $ - ### $ 28,163 $ 25,000 $ (3,163) 2
64 Sonoma MCOE Laytonville 11/12-2 Err:520 $ 34,062 $ 25,547 $ 8,515 $ - ### $ - 2 2812
65 Sonoma MCOE Laytonville 10/11-3 Err:520 $ 29,963 $ 25,000 $ 4,963 $ - ### $ - 2 898
66 Sonoma MCOE Laytonville 11/12-3 Err:520 $ 36,073 $ 27,055 $ 9,018 $ - ### $ - 2 3611
67 Sonoma MCOE Laytonville 10/11-4 Err:520 $ 29,953 $ 25,000 $ 4,953 $ - ### $ - 2 1369
68 Sonoma MCOE Laytonville 11/12-4 Err:520 $ 35,934 $ 26,951 $ 8,983 $ - ### $ - 2 4388
69 MCOE Laytonville Total $ 198,034 $ 154,553 $ 43,481 $ 55,840 $ 50,000 $ (5,840) $ 148,713
70 Sonoma MCOE SELPA 10/11-1 2012-Q4 $ - $ - ### $ 41,228 $ 30,921 $ (10,307) 2
71 Sonoma MCOE SELPA 11/12-1 Err:520 $ 51,990 $ 20,796 $ 31,194 $ - ### $ - 2038
72 Sonoma MCOE SELPA 10/11-2 2013-Q1 $ - $ - ### $ 43,615 $ 32,711 $ (10,904) 2
73 Sonoma MCOE SELPA 11/12-2 Err:520 $ 44,204 $ 33,153 $ 11,051 $ - ### $ - 2 2812
74 Sonoma MCOE SELPA 10/11-3 Err:520 $ 47,023 $ 35,267 $ 11,756 $ - ### $ - 2 903
75 Sonoma MCOE SELPA 11/12-3 Err:520 $ 42,908 $ 32,181 $ 10,727 $ - ### $ - 2 3621
76 Sonoma MCOE SELPA 09/10-4 2012-Q3 $ - $ - ### $ 50,465 $ 20,186 $ (30,279)
A B C D E F G H I J K L M
Period of Submitted for Amount to be recouped
1 Service Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
77 Sonoma MCOE SELPA 10/11-4 Err:520 $ 40,156 $ 30,117 $ 10,039 $ - ### $ - 2 1374
78 Sonoma MCOE SELPA 11/12-4 Err:520 $ 49,449 $ 37,087 $ 12,362 $ - ### $ - 2 4394
79 MCOE SELPA Total $ 275,730 $ 188,601 $ 87,129 $ 135,308 $ 83,818 $ (51,490) $ 137,111
80 Sonoma MCOE Sp Ed 10/11-2 2013-Q1 $ - $ - ### $ 36,363 $ 36,363 $ - 2
81 Sonoma MCOE Sp Ed 11/12-2 Err:520 $ - $ - $ - ### $ - 2
82 Sonoma MCOE Sp Ed 09/10-4 2012-Q3 $ - $ - ### $ 35,247 $ 35,247 $ - 2
83 Sonoma MCOE Sp Ed 11/12-4 Err:520 $ 35,682 $ 35,682 $ - $ - ### $ - 2 4395
84 MCOE Sp Ed Total $ 35,682 $ 35,682 $ - $ 71,610 $ 71,610 $ - $ 35,682
85 Sonoma MCOE Ukiah 10/11-1 2012-Q4 $ - $ - ### $ 55,166 $ 22,066 $ (33,100)
86 Sonoma MCOE Ukiah 11/12-1 Err:520 $ 65,734 $ 26,294 $ 39,440 $ - ### $ - 2039
87 Sonoma MCOE Ukiah 10/11-2 2013-Q1 $ - $ - ### $ 67,932 $ 27,173 $ (40,759)
88 Sonoma MCOE Ukiah 11/12-2 Err:520 $ 75,739 $ 30,296 $ 45,443 $ - ### $ - 2820
89 Sonoma MCOE Ukiah 10/11-3 Err:520 $ 79,273 $ 31,709 $ 47,564 $ - ### $ - 905
90 Sonoma MCOE Ukiah 11/12-3 Err:520 $ 70,138 $ 28,055 $ 42,083 $ - ### $ - 3622
91 Sonoma MCOE Ukiah 09/10-4 2012-Q3 $ - $ - ### $ 45,370 $ 34,028 $ (11,342) 2
92 Sonoma MCOE Ukiah 10/11-4 Err:520 $ 67,416 $ 26,966 $ 40,450 $ - ### $ - 1376
93 Sonoma MCOE Ukiah 11/12-4 Err:520 $ 77,365 $ 30,946 $ 46,419 $ - ### $ - 4396
94 MCOE Ukiah Total $ 435,665 $ 174,266 $ 261,399 $ 168,468 $ 83,267 $ (85,201) $ 89,065
95 Sonoma MCOE Willits 10/11-1 2012-Q4 $ - $ - ### $ 29,386 $ 25,000 $ (4,386) 2
96 Sonoma MCOE Willits 11/12-1 Err:520 $ 36,674 $ 27,506 $ 9,168 $ - ### $ - 2 2040
97 Sonoma MCOE Willits 10/11-2 Err:520 $ 50,177 $ 20,071 $ 30,106 $ - ### $ - 624
98 Sonoma MCOE Willits 11/12-2 Err:520 $ 47,195 $ 35,396 $ 11,799 $ - ### $ - 2 2821
99 Sonoma MCOE Willits 10/11-3 Err:520 $ 48,294 $ 36,221 $ 12,073 $ - ### $ - 2 906
100 Sonoma MCOE Willits 11/12-3 Err:520 $ 54,953 $ 21,981 $ 32,972 $ - ### $ - 3623
101 Sonoma MCOE Willits 09/10-4 2012-Q3 $ - $ - ### $ 40,940 $ 30,705 $ (10,235) 2
102 Sonoma MCOE Willits 10/11-4 Err:520 $ 52,723 $ 21,089 $ 31,634 $ - ### $ - 1377
103 Sonoma MCOE Willits 11/12-4 Err:520 $ 58,979 $ 23,592 $ 35,387 $ - ### $ - 4397
104 MCOE Willits Total $ 348,995 $ 185,856 $ 163,139 $ 70,326 $ 55,705 $ (14,621) $ 171,235
105 Sonoma Northern Humboldt Union HSD 11/12-2 Err:520 $ 28,999 $ 25,000 $ 3,999 $ - ### $ - 2 2824
106 Northern Humboldt Union HSD Total $ 28,999 $ 25,000 $ 3,999 $ - $ - $ - $ 25,000
107 Sonoma Rincon Valley Union ESD 10/11-1 2012-Q4 $ - $ - ### $ 30,805 $ 23,104 $ (7,701) 1
108 Sonoma Rincon Valley Union ESD 11/12-1 Err:520 $ 29,752 $ 22,314 $ 7,438 $ - ### $ - 1 2050
109 Sonoma Rincon Valley Union ESD 10/11-2 2013-Q1 $ - $ - ### $ 47,169 $ 35,377 $ (11,792) 1
110 Sonoma Rincon Valley Union ESD 11/12-2 Err:520 $ 34,925 $ 26,194 $ 8,731 $ - ### $ - 1 2831
111 Sonoma Rincon Valley Union ESD 10/11-3 Err:520 $ 36,456 $ 27,342 $ 9,114 $ - ### $ - 1 913
112 Sonoma Rincon Valley Union ESD 11/12-3 Err:520 $ 36,387 $ 27,290 $ 9,097 $ - ### $ - 1 3632
113 Sonoma Rincon Valley Union ESD 10/11-4 Err:520 $ 27,503 $ 20,627 $ 6,876 $ - ### $ - 1 1384
114 Sonoma Rincon Valley Union ESD 11/12-4 Err:520 $ 29,811 $ 22,358 $ 7,453 $ - ### $ - 1 4406
115 Rincon Valley Union ESD Total $ 194,834 $ 146,125 $ 48,709 $ 77,974 $ 58,481 $ (19,493) $ 126,632
116 Sonoma Santa Rosa Junior College 11/12-3 Err:520 $ 26,097 $ 25,000 $ 1,097 $ - ### $ - 2 3636
117 Santa Rosa Junior College Total $ 26,097 $ 25,000 $ 1,097 $ - $ - $ - $ 25,000
118 Sonoma Sonoma COE-Sp Ed 10/11-1 2012-Q4 $ - $ - ### $ 32,397 $ 25,000 $ (7,397) 2
119 Sonoma Sonoma COE-Sp Ed 10/11-2 2013-Q1 $ - $ - ### $ 27,319 $ 25,000 $ (2,319) 2
120 Sonoma Sonoma COE-Sp Ed 11/12-2 Err:520 $ 26,841 $ 25,000 $ 1,841 $ - ### $ - 2 2840
121 Sonoma Sonoma COE-Sp Ed 10/11-3 Err:520 $ 31,573 $ 25,000 $ 6,573 $ - ### $ - 2 922
122 Sonoma Sonoma COE-Sp Ed 09/10-4 2012-Q3 $ - $ - ### $ 25,872 $ 25,000 $ (872) 2
123 Sonoma COE-Sp Ed Total* $ 58,414.00 $ 50,000.00 $ 8,414.00 $ 85,588 $ 75,000 $ (10,588) $ 39,412
124 Sonoma South Bay Union ESD 09/10-4 2012-Q3 $ - $ - ### $ 27,366 $ 25,000 $ (2,366) 2
125 Sonoma South Bay Union ESD 12/13-1 Err:520 $ 12,883 $ 11,595 $ 1,288 5183
126 South Bay Union ESD Total $ 12,883.00 $ 11,595.00 $ 1,288.00 $ 27,366 $ 25,000 $ (2,366) $ 9,229
127 Grand Total Sonoma LEC Err:502 Err:502 Err:502 Err:502 Err:502 Err:502 Err:502
128
129
130 Column A County - Reporting LEC/LGA
131 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
132 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
133 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
134 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
135 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
136 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
137 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
138 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
139 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
140 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
141 The last subtotal amount is the final amount due to/from the LEC/LGA
142 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
143

144 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
145 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
146 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
A B C D E F G H I J K L M
Period of Submitted for Amount to be recouped
1 Service Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
147

148 Released
Claiming Unit Invoice on placeholder to be paid 100%
149

150 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
151 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
152

153 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
154 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
155 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
156 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
157

158 Claiming units no longer participating (5% reduction)


159
160 12/13 claims
161 13/14 claims
A B C D E F G H I J K L M N O P Q R

1
Pro-Rata Net Negative Distribution Table
Total amount
2 Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata Amount to release to 2013 and CUs in Option (insert 1 Modesto Jr. College -
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent claiming unit Red) or 2) Hughson USD Lammersville ESD Yosemite CCD
3 Stanislaus Amador County USD 10/11-1 2012-Q4 $ - $ - ### $ 30,667 $ 25,000 $ (5,667) 2
4 Stanislaus Amador County USD 11/12-1 Err:520 $ 41,654 $ 31,241 $ 10,413 $ - ### $ - 2
5 Stanislaus Amador County USD 10/11-2 2013-Q1 $ - $ - ### $ 25,923 $ 25,000 $ (923) 2
6 Stanislaus Amador County USD 11/12-2 Err:520 $ 33,221 $ 25,000 $ 8,221 $ - ### $ - 2
7 Stanislaus Amador County USD 10/11-3 2013-Q2 $ - $ - ### $ 29,079 $ 25,000 $ (4,079) 2
8 Stanislaus Amador County USD 11/12-3 Err:520 $ 27,542 $ 25,000 $ 2,542 $ - ### $ - 2
9 Stanislaus Amador County USD 10/11-4 2013-Q3 $ - $ - ### $ 28,237 $ 25,000 $ (3,237) 2
10 Stanislaus Amador County USD 11/12-4 Err:520 $ 34,277 $ 25,708 $ 8,569 $ - ### $ - 2
11 Amador County USD Total $ 136,694 $ 106,949 $ 29,745 $ 113,906 $ 100,000 $ (13,906) $ 93,043 2.08% $ 15,999 $ 77,044 $ 172.91 $ 1,588.41 $ 196.46
12 Stanislaus Calaveras COE 10/11-1 2012-Q4 $ - $ - ### $ 25,764 $ 25,000 $ (764) 2
13 Stanislaus Calaveras COE 12/13-1 Err:520 $ 2,438 $ 2,194 $ 244
14 Calaveras COE Total $ 2,438 $ 2,194 $ 244 $ 25,764 $ 25,000 $ (764) $ 1,430 0.03% $ 246 $ 1,184 $ 2.66 $ 24.41 $ 3.02
15 Stanislaus Ceres USD 10/11-1 2012-Q4 $ - $ - ### $ 151,918 $ 60,767 $ (91,151)
16 Stanislaus Ceres USD 11/12-1 Err:520 $ 115,842 $ 46,337 $ 69,505 $ - ### $ -
17 Stanislaus Ceres USD 10/11-2 2013-Q1 $ - $ - ### $ 177,473 $ 70,989 $ (106,484)
18 Stanislaus Ceres USD 11/12-2 Err:520 $ 112,550 $ 45,020 $ 67,530 $ - ### $ -
19 Stanislaus Ceres USD 10/11-3 2013-Q2 $ - $ - ### $ 123,419 $ 49,368 $ (74,051)
20 Stanislaus Ceres USD 11/12-3 Err:520 $ 115,915 $ 46,366 $ 69,549 $ - ### $ -
21 Stanislaus Ceres USD 10/11-4 2013-Q3 $ - $ - ### $ 173,898 $ 69,559 $ (104,339)
22 Stanislaus Ceres USD 12/13-1 Err:520 $ 85,437 $ 34,175 $ 51,262
23 Stanislaus Ceres USD 12/13-2 Err:520 $ 70,298 $ 28,119 $ 42,179
24 Stanislaus Ceres USD 12/13-3 Err:520 $ 85,354 $ 34,142 $ 51,212
25 Stanislaus Ceres USD 12/13-4 Err:520 $ 79,864 $ 31,946 $ 47,918
26 Stanislaus Ceres USD 13/14-1 Err:520 $ 52,543 $ 21,017 $ 31,526
27 Stanislaus Ceres USD 13/14-2 Err:520 $ 93,344 $ 37,338 $ 56,006
28 Stanislaus Ceres USD 11/12-4 Err:520 $ 132,898 $ 53,159 $ 79,739 $ - ### $ -
29 Ceres USD Total $ 944,045 $ 377,619 $ 566,426 $ 626,708 $ 250,683 $ (376,025) $ 1,594 0.04% $ 274 $ 1,320 $ 2.96 $ 27.21 $ 3.37
30 Stanislaus Denair USD 11/12-1 Err:520 $ 37,913 $ 28,435 $ 9,478 $ - ### $ - 2
31 Stanislaus Denair USD 10/11-2 2013-Q1 $ - $ - ### $ 29,087 $ 25,000 $ (4,087) 2
32 Stanislaus Denair USD 11/12-2 Err:520 $ 43,825 $ 32,869 $ 10,956 $ - ### $ - 2
33 Stanislaus Denair USD 10/11-3 2013-Q2 $ - $ - ### $ 25,349 $ 25,000 $ (349) 2
34 Stanislaus Denair USD 11/12-3 Err:520 $ 31,855 $ 25,000 $ 6,855 $ - ### $ - 2
35 Denair USD Total $ 113,593 $ 86,304 $ 27,289 $ 54,436 $ 50,000 $ (4,436) $ 81,868 1.83% $ 14,077 $ 67,791 $ 152.15 $ 1,397.63 $ 172.86
36 Stanislaus Empire Union SD 10/11-1 2012-Q4 $ - $ - ### $ 102,232 $ 40,893 $ (61,339)
37 Stanislaus Empire Union SD 11/12-1 Err:520 $ 96,714 $ 38,686 $ 58,028 $ - ### $ -
38 Stanislaus Empire Union SD 10/11-2 2013-Q1 $ - $ - ### $ 38,347 $ 28,760 $ (9,587) 2
39 Stanislaus Empire Union SD 11/12-2 Err:520 $ 84,028 $ 33,611 $ 50,417 $ - ### $ -
40 Stanislaus Empire Union SD 10/11-3 2013-Q2 $ - $ - ### $ 32,971 $ 25,000 $ (7,971) 2
41 Stanislaus Empire Union SD 11/12-3 Err:520 $ 65,488 $ 26,195 $ 39,293 $ - ### $ -
42 Stanislaus Empire Union SD 10/11-4 2013-Q3 $ - $ - ### $ 36,163 $ 27,122 $ (9,041) 2
43 Stanislaus Empire Union SD 11/12-4 Err:520 $ 63,398 $ 25,359 $ 38,039 $ - ### $ -
44 Empire Union SD Total $ 309,628 $ 123,851 $ 185,777 $ 209,713 $ 121,775 $ (87,938) $ 35,913 0.80% $ 6,175 $ 29,738 $ 66.74 $ 613.10 $ 75.83
45 Stanislaus Escalon USD 10/11-2 2013-Q1 $ - $ - ### $ 44,802 $ 33,602 $ (11,200) 2
46 Stanislaus Escalon USD 10/11-3 2013-Q2 $ - $ - ### $ 25,578 $ 25,000 $ (578) 2
47 Stanislaus Escalon USD 11/12-1C-1 Err:520 $ 26,793 $ 25,000 $ 1,793 $ - ### $ - 2
48 Stanislaus Escalon USD 11/12-2C-1 Err:520 $ 28,125 $ 25,000 $ 3,125 $ - ### $ - 2
49 Escalon USD Total $ 54,918 $ 50,000 $ 4,918 $ 70,380 $ 58,602 $ (11,778) $ 38,222 0.85% $ 6,572 $ 31,650 $ 71.03 $ 652.52 $ 80.70
50 Stanislaus Hughson USD 10/11-1 2012-Q4 $ - $ - ### $ 27,736 $ 19,415 $ (8,321) 2
51 Hughson USD Total $ - $ - $ - $ 27,736 $ 19,415 $ (8,321) $ (8,321) 8.83%
52 Stanislaus Jefferson Elementary SD 11/12-2 Err:520 $ 39,445 $ 29,584 $ 9,861 $ - ### $ - 2
53 Stanislaus Jefferson Elementary SD 11/12-4 Err:520 $ 25,756 $ 25,000 $ 756 $ - ### $ - 2
54 Jefferson Elementary SD Total $ 65,201 $ 54,584 $ 10,617 $ - $ - $ - $ 54,584 1.22% $ 9,386 $ 45,198 $ 101.44 $ 931.85 $ 115.25
55 Stanislaus Lammersville ESD 10/11-1 2012-Q4 $ - $ - ### $ 44,904 $ 33,678 $ (11,226) 2
56 Stanislaus Lammersville ESD 11/12-1 Err:520 $ 30,419 $ 25,000 $ 5,419 $ - ### $ - 2
57 Stanislaus Lammersville ESD 10/11-2 2013-Q1 $ - $ - ### $ 69,080 $ 27,632 $ (41,448)
58 Stanislaus Lammersville ESD 11/12-2 Err:520 $ - $ - $ - ### $ -
59 Stanislaus Lammersville ESD 10/11-3 2013-Q2 $ - $ - ### $ 56,660 $ 22,664 $ (33,996)
60 Stanislaus Lammersville ESD 11/12-3 Err:520 $ - $ - $ - ### $ -
61 Stanislaus Lammersville ESD 10/11-4 2013-Q3 $ - $ - ### $ 67,906 $ 27,162 $ (40,744)
62 Stanislaus Lammersville ESD 12/13-1 Err:520 $ 2,355 $ 2,120 $ 235
63 Stanislaus Lammersville ESD 12/13-2 Err:520 $ 5,781 $ 5,203 $ 578
64 Stanislaus Lammersville ESD 12/13-3 Err:520 $ 3,496 $ 3,146 $ 350
65 Stanislaus Lammersville ESD 12/13-4 Err:520 $ 3,898 $ 3,508 $ 390
66 Stanislaus Lammersville ESD 13/14-1 Err:520 $ 2,660 $ 2,394 $ 266
67 Stanislaus Lammersville ESD 13/14-2 Err:520 $ 5,195 $ 4,676 $ 519
68 Stanislaus Lammersville ESD 13/14-3 Err:520 $ 3,670 $ 3,303 $ 367
69 Stanislaus Lammersville ESD 13/14-4 Err:520 $ 1,807 $ 1,626 $ 181
70 Stanislaus Lammersville ESD 11/12-4 Err:520 $ - $ - $ - ### $ -
71 Lammersville ESD Total $ 59,281 $ 50,976 $ 8,305 $ 238,550 $ 111,136 $ (127,414) $ (76,438) 81.13%
72 Stanislaus Lincoln USD 10/11-1 2012-Q4 $ - $ - ### $ 35,502 $ 26,627 $ (8,875) 2
73 Stanislaus Lincoln USD 11/12-1 Err:520 $ 26,090 $ 25,000 $ 1,090 $ - ### $ - 2
74 Stanislaus Lincoln USD 10/11-2 2013-Q1 $ - $ - ### $ 54,740 $ 21,896 $ (32,844)
75 Stanislaus Lincoln USD 11/12-2 Err:520 $ 31,646 $ 25,000 $ 6,646 $ - ### $ - 2
76 Stanislaus Lincoln USD 10/11-3 Err:520 $ 44,969 $ 33,727 $ 11,242 $ - ### $ - 2
77 Stanislaus Lincoln USD 11/12-3 Err:520 $ 40,137 $ 30,103 $ 10,034 $ - ### $ - 2
78 Stanislaus Lincoln USD 09/10-4 2012-Q3 $ - $ - ### $ 48,936 $ 36,702 $ (12,234) 2
79 Stanislaus Lincoln USD 10/11-4 Err:520 $ 47,346 $ 35,510 $ 11,836 $ - ### $ - 2
80 Lincoln USD Total $ 190,188 $ 149,340 $ 40,848 $ 139,178 $ 85,225 $ (53,953) $ 95,387 2.13% $ 16,402 $ 78,985 $ 177.27 $ 1,628.42 $ 201.41
81 Stanislaus Linden USD 10/11-2 2013-Q1 $ - $ - ### $ 47,563 $ 47,563 $ -
82 Stanislaus Linden USD 10/11-3 2013-Q2 $ - $ - ### $ 25,297 $ 25,297 $ -
83 Stanislaus Linden USD 10/11-4 2013-Q3 $ - $ - ### $ 41,965 $ 41,965 $ -
84 Linden USD Total $ - $ - $ - $ 114,825 $ 114,825 $ - $ -
85 Stanislaus Lodi USD 10/11-1 Err:520 $ 398,405 $ - ### $ -
86 Stanislaus Lodi USD 10/11-2 Err:520 $ 455,552 $ 182,221 $ 273,331 $ - ### $ -
87 Stanislaus Lodi USD 11/12-2 Err:520 $ 233,521 $ 93,408 $ 140,113 $ - ### $ -
88 Stanislaus Lodi USD 10/11-3 Err:520 $ 381,506 $ 152,602 $ 228,904 $ - ### $ -
89 Stanislaus Lodi USD 11/12-3 Err:520 $ 294,235 $ 117,694 $ 176,541 $ - ### $ -
90 Stanislaus Lodi USD 10/11-4 Err:520 $ 330,942 $ 132,377 $ 198,565 $ - ### $ -
91 Stanislaus Lodi USD 11/12-4 Err:520 $ 145,673 $ 58,269 $ 87,404 $ - ### $ -
92 Stanislaus Lodi USD 11/12-1C-1 Err:520 $ 212,452 $ 84,981 $ 127,471 $ - ### $ -
93 Lodi USD Total $ 2,452,286 $ 821,552 $ 1,232,329 $ - $ - $ - $ 821,552 18.35% $ 141,267 $ 680,285 $ 1,526.79 $ 14,025.34 $ 1,734.68
94 Stanislaus Manteca USD 10/11-1 Err:520 $ 436,225 $ - ### $ -
95 Stanislaus Manteca USD 11/12-1 Err:520 $ 330,953 $ 132,381 $ 198,572 $ - ### $ -
96 Stanislaus Manteca USD 10/11-2 Err:520 $ 521,615 $ 208,646 $ 312,969 $ - ### $ -
97 Stanislaus Manteca USD 11/12-2 Err:520 $ 520,591 $ 208,236 $ 312,355 $ - ### $ -
98 Stanislaus Manteca USD 10/11-3 Err:520 $ 540,846 $ 216,338 $ 324,508 $ - ### $ -
99 Stanislaus Manteca USD 11/12-3 Err:520 $ 341,578 $ 136,631 $ 204,947 $ - ### $ -
100 Stanislaus Manteca USD 10/11-4 Err:520 $ 627,834 $ 251,134 $ 376,700 $ - ### $ -
101 Stanislaus Manteca USD 11/12-4C-1 Err:520 $ 108,777 $ 43,511 $ 65,266 $ - ### $ -
102 Manteca USD Total $ 3,428,419 $ 1,196,877 $ 1,795,317 $ - $ - $ - $ 1,196,877 26.73% $ 205,805 $ 991,072 $ 2,224.30 $ 20,432.81 $ 2,527.17
103 Stanislaus Modesto City Schools 10/11-1 2012-Q4 $ - $ - ### $ 127,579 $ 44,653 $ (82,926)
104 Stanislaus Modesto City Schools 11/12-1 Err:520 $ 91,648 $ 32,077 $ 59,571 $ - ### $ -
105 Stanislaus Modesto City Schools 10/11-2 2013-Q1 $ - $ - ### $ 119,714 $ 41,900 $ (77,814)
106 Stanislaus Modesto City Schools 11/12-2 Err:520 $ 107,728 $ 37,705 $ 70,023 $ - ### $ -
107 Stanislaus Modesto City Schools 10/11-3 2013-Q2 $ - $ - ### $ 99,576 $ 34,852 $ (64,724)
108 Stanislaus Modesto City Schools 11/12-3 Err:520 $ 113,425 $ 39,699 $ 73,726 $ - ### $ -
109 Stanislaus Modesto City Schools 10/11-4 2013-Q3 $ - $ - ### $ 103,316 $ 36,161 $ (67,155)
110 Stanislaus Modesto City Schools 12/13-1 Err:520 $ 45,313 $ 31,719 $ 13,594
111 Stanislaus Modesto City Schools 12/13-2 Err:520 $ 39,040 $ 27,328 $ 11,712
112 Stanislaus Modesto City Schools 12/13-3 Err:520 $ 47,595 $ 33,317 $ 14,278
113 Stanislaus Modesto City Schools 12/13-4 Err:520 $ 40,858 $ 28,601 $ 12,257
114 Stanislaus Modesto City Schools 13/14-1 Err:520 $ 22,558 $ 22,558 $ -
115 Stanislaus Modesto City Schools 13/14-2 Err:520 $ 68,945 $ 24,131 $ 44,814
116 Stanislaus Modesto City Schools 11/12-4 Err:520 $ 80,863 $ 28,302 $ 52,561 $ - ### $ -
117 Modesto City Schools Total $ 657,973 $ 305,437 $ 352,536 $ 450,185 $ 157,566 $ (292,619) $ 12,818 0.29% $ 2,204 $ 10,614 $ 23.82 $ 218.83 $ 27.06
118 Stanislaus Modesto Jr. College - Yosemite CCD 10/11-1 2012-Q4 $ - $ - ### $ 48,046 $ 36,035 $ (12,011) 2
119 Stanislaus Modesto Jr. College - Yosemite CCD 12/13-1 Err:520 $ 2,396 $ 2,156 $ 240
120 Stanislaus Modesto Jr. College - Yosemite CCD 12/13-3 Err:520 $ 14 $ 13 $ 1
121 Stanislaus Modesto Jr. College - Yosemite CCD 13/14-3 Err:520 $ 226 $ 203 $ 23
122 Stanislaus Modesto Jr. College - Yosemite CCD 13/14-4 Err:520 $ 205 $ 185 $ 20
123 Modesto Jr. College - Yosemite CCD Total $ 2,841 $ 2,557 $ 284 $ 48,046 $ 36,035 $ (12,011) $ (9,454) 10.03%
124 Stanislaus Newman-Crows Landing USD 10/11-3 Err:520 $ 33,211 $ 25,000 $ 8,211 $ - ### $ - 2
125 Newman-Crows Landing USD Total $ 33,211 $ 25,000 $ 8,211 $ - $ - $ - $ 25,000 0.56% $ 4,299 $ 20,701 $ 46.46 $ 426.79 $ 52.79
126 Stanislaus Oakdale JUSD 11/12-1 Err:520 $ 77,382 $ 30,953 $ 46,429 $ - ### $ -
A B C D E F G H I J K L M N O P Q R

Total amount
2 Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata Amount to release to 2013 and CUs in Option (insert 1 Modesto Jr. College -
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent claiming unit Red) or 2) Hughson USD Lammersville ESD Yosemite CCD
127 Stanislaus Oakdale JUSD 10/11-2 2013-Q1 $ - $ - ### $ 27,100 $ 25,000 $ (2,100) 2
128 Stanislaus Oakdale JUSD 11/12-2 Err:520 $ 78,184 $ 31,274 $ 46,910 $ - ### $ -
129 Stanislaus Oakdale JUSD 11/12-3 Err:520 $ 59,842 $ 23,937 $ 35,905 $ - ### $ -
130 Stanislaus Oakdale JUSD 10/11-4 2013-Q3 $ - $ - ### $ 31,650 $ 25,000 $ (6,650) 2
131 Stanislaus Oakdale JUSD 11/12-4 Err:520 $ 73,668 $ 29,467 $ 44,201 $ - ### $ -
132 Oakdale JUSD Total $ 289,076 $ 115,631 $ 173,445 $ 58,750 $ 50,000 $ (8,750) $ 106,881 2.39% $ 18,378 $ 88,503 $ 198.63 $ 1,824.65 $ 225.68
133 Stanislaus Patterson JUSD 10/11-1 Err:520 $ 75,451 $ - ### $ -
134 Stanislaus Patterson JUSD 10/11-2 Err:520 $ 129,417 $ 51,767 $ 77,650 $ - ### $ -
135 Stanislaus Patterson JUSD 11/12-2 Err:520 $ 71,076 $ 28,430 $ 42,646 $ - ### $ -
136 Stanislaus Patterson JUSD 10/11-3 Err:520 $ 135,207 $ 54,083 $ 81,124 $ - ### $ -
137 Stanislaus Patterson JUSD 11/12-3 Err:520 $ 41,989 $ 31,492 $ 10,497 $ - ### $ - 2
138 Stanislaus Patterson JUSD 10/11-4 Err:520 $ 92,701 $ 37,080 $ 55,621 $ - ### $ -
139 Stanislaus Patterson JUSD 11/12-4 Err:520 $ 37,119 $ 27,839 $ 9,280 $ - ### $ - 2
140 Patterson JUSD Total $ 582,960 $ 230,691 $ 276,818 $ - $ - $ - $ 230,691 5.15% $ 39,668 $ 191,023 $ 428.72 $ 3,938.30 $ 487.10
141 Stanislaus San Joaquin COE - Creative Child Care 10/11-1 2012-Q4 $ - $ - ### $ 29,901 2
142 Stanislaus San Joaquin COE - Creative Child Care 12/13-1 Err:520 $ 2,007 $ 1,806 $ 201
143 Stanislaus San Joaquin COE - Creative Child Care 12/13-2 Err:520 $ 2,416 $ 2,174 $ 242
144 Stanislaus San Joaquin COE - Creative Child Care 12/13-3 Err:520 $ 574 $ 517 $ 57
145 Stanislaus San Joaquin COE - Creative Child Care 13/14-2 Err:520 $ 932 $ 839 $ 93
146 Stanislaus San Joaquin COE - Creative Child Care 10/11-2 2013-Q1 $ - $ - ### $ 29,776 $ 25,000 $ (4,776) 2
147 San Joaquin COE - Creative Child Care Total $ 5,929.00 $ 5,336.00 $ 593.00 $ 59,677 $ 25,000 $ (4,776) $ 560 0.01% $ 96 $ 464 $ 1.04 $ 9.56 $ 1.18
148 Stanislaus San Joaquin COE - SJCOE 11/12-1 Err:520 $ 171,687 $ 68,675 $ 103,012 $ - ### $ -
149 Stanislaus San Joaquin COE - SJCOE 10/11-2 Err:520 $ 187,740 $ 75,096 $ 112,644 $ - ### $ -
150 Stanislaus San Joaquin COE - SJCOE 11/12-2 Err:520 $ 210,611 $ 84,244 $ 126,367 $ - ### $ -
151 Stanislaus San Joaquin COE - SJCOE 10/11-3 Err:520 $ 185,591 $ 74,236 $ 111,355 $ - ### $ -
152 Stanislaus San Joaquin COE - SJCOE 11/12-3 Err:520 $ 209,831 $ 83,932 $ 125,899 $ - ### $ -
153 Stanislaus San Joaquin COE - SJCOE 10/11-4 Err:520 $ 236,664 $ 94,666 $ 141,998 $ - ### $ -
154 Stanislaus San Joaquin COE-SJCOE 10/11-1 Err:520 $ 219,569 $ - ### $ -
155 Stanislaus San Joaquin COE - SJCOE 11/12-4 Err:520 $ 168,190 $ 67,276 $ 100,914 $ - ### $ -
156 San Joaquin COE - SJCOE Total* $ 1,589,883 $ 548,125 $ 822,189 $ - $ - $ - $ 548,125 12.24% $ 94,251 $ 453,874 $ 1,018.65 $ 9,357.46 $ 1,157.35
157 Stanislaus Stanislaus COE 10/11-1 2012-Q4 $ - $ - ### $ 259,834 $ 103,934 $ (155,900)
158 Stanislaus Stanislaus COE 11/12-1 Err:520 $ 167,951 $ 67,180 $ 100,771 $ - ### $ -
159 Stanislaus Stanislaus COE 10/11-2 Err:520 $ 249,944 $ 99,978 $ 149,966 $ - ### $ -
160 Stanislaus Stanislaus COE 11/12-2 Err:520 $ 195,522 $ 78,209 $ 117,313 $ - ### $ -
161 Stanislaus Stanislaus COE 10/11-3 Err:520 $ 218,896 $ 87,558 $ 131,338 $ - ### $ -
162 Stanislaus Stanislaus COE 11/12-3 Err:520 $ 173,123 $ 69,249 $ 103,874 $ - ### $ -
163 Stanislaus Stanislaus COE 10/11-4 Err:520 $ 262,581 $ 105,032 $ 157,549 $ - ### $ -
164 Stanislaus Stanislaus COE 11/12-4 Err:520 $ 193,487 $ 77,395 $ 116,092 $ - ### $ -
165 Stanislaus COE Total $ 1,461,504 $ 584,601 $ 876,903 $ 259,834 $ 103,934 $ (155,900) $ 428,701 9.57% $ 73,716 $ 354,985 $ 796.71 $ 7,318.68 $ 905.19
166 Stanislaus Stanislaus Union SD 10/11-1 2012-Q4 $ - $ - ### $ 47,647 $ 35,735 $ (11,912) 2
167 Stanislaus Stanislaus Union SD 11/12-1 Err:520 $ 70,093 $ 28,037 $ 42,056 $ - ### $ -
168 Stanislaus Stanislaus Union SD 10/11-2 2013-Q1 $ - $ - ### $ 43,414 $ 32,561 $ (10,853) 2
169 Stanislaus Stanislaus Union SD 11/12-2 Err:520 $ - $ - $ - ### $ -
170 Stanislaus Stanislaus Union SD 10/11-3 2013-Q2 $ - $ - ### $ 43,755 $ 32,816 $ (10,939) 2
171 Stanislaus Stanislaus Union SD 10/11-4 2013-Q3 $ - $ - ### $ 46,520 $ 34,890 $ (11,630) 2
172 Stanislaus Stanislaus Union SD 11/12-4 Err:520 $ - $ - $ - ### $ -
173 Stanislaus Stanislaus Union SD 11/12-3C-1 Err:520 $ - $ - $ - ### $ -
174 Stanislaus Stanislaus Union SD 12/13-1 Err:520 $ 25,872 $ 19,404 $ 6,468
175 Stanislaus Stanislaus Union SD 11/12-4C-2 Err:520 $ - $ - $ - ### $ -
176 Stanislaus Union SD Total $ 95,965 $ 47,441 $ 48,524 $ 181,336 $ 136,002 $ (45,334) $ 2,107 0.05% $ 362 $ 1,745 $ 3.92 $ 35.97 $ 4.45
177 Stanislaus Stockton USD 10/11-1 2012-Q4 $ - $ - ### $ 553,522 $ 221,409 $ (332,113)
178 Stanislaus Stockton USD 11/12-1 Err:520 $ 763,254 $ 305,302 $ 457,952 $ - ### $ -
179 Stanislaus Stockton USD 10/11-2 2013-Q1 $ - $ - ### $ 718,024 $ 287,210 $ (430,814)
180 Stanislaus Stockton USD 11/12-2 Err:520 $ 574,024 $ 229,610 $ 344,414 $ - ### $ -
181 Stanislaus Stockton USD 10/11-3 2013-Q2 $ - $ - ### $ 829,664 $ 331,866 $ (497,798)
182 Stanislaus Stockton USD 10/11-4 2013-Q3 $ - $ - ### $ 647,466 $ 258,986 $ (388,480)
183 Stanislaus Stockton USD 11/12-3C-1 Err:520 $ 448,415 $ 179,366 $ 269,049 $ - ### $ -
184 Stanislaus Stockton USD 12/13-1 Err:520 $ 313,122 $ 125,249 $ 187,873
185 Stanislaus Stockton USD 12/13-2 Err:520 $ 260,313 $ 104,125 $ 156,188
186 Stanislaus Stockton USD 12/13-3 Err:520 $ 333,934 $ 133,574 $ 200,360
187 Stanislaus Stockton USD 12/13-4 Err:520 $ 198,270 $ 79,308 $ 118,962
188 Stanislaus Stockton USD 13/14-1 Err:520 $ 260,203 $ 104,081 $ 156,122
189 Stanislaus Stockton USD 13/14-2 Err:520 $ 365,150 $ 146,060 $ 219,090
190 Stanislaus Stockton USD 13/14-3 Err:520 $ 350,066 $ 140,026 $ 210,040
191 Stanislaus Stockton USD 11/12-4C-1 Err:520 $ 332,772 $ 133,109 $ 199,663 $ - ### $ -
192 Stockton USD Total $ 4,199,523 $ 1,679,810 $ 2,519,713 $ 2,748,676 $ 1,099,471 $ (1,649,205) $ 30,605 0.68% $ 5,263 $ 25,342 $ 56.88 $ 522.48 $ 64.62
193 Stanislaus Sylvan Union SD 10/11-1 2012-Q4 $ - $ - ### $ 92,747 $ 37,099 $ (55,648)
194 Stanislaus Sylvan Union SD 11/12-1 Err:520 $ 87,026 $ 34,810 $ 52,216 $ - ### $ -
195 Stanislaus Sylvan Union SD 10/11-2 2013-Q1 $ - $ - ### $ 110,093 $ 44,037 $ (66,056)
196 Stanislaus Sylvan Union SD 11/12-2 Err:520 $ 94,972 $ 37,989 $ 56,983 $ - ### $ -
197 Stanislaus Sylvan Union SD 10/11-3 2013-Q2 $ - $ - ### $ 110,015 $ 44,006 $ (66,009)
198 Stanislaus Sylvan Union SD 11/12-3 Err:520 $ 126,721 $ 50,688 $ 76,033 $ - ### $ -
199 Stanislaus Sylvan Union SD 10/11-4 2013-Q3 $ - $ - ### $ 82,450 $ 32,980 $ (49,470)
200 Stanislaus Sylvan Union SD 12/13-1 Err:520 $ 68,734 $ 27,494 $ 41,240
201 Stanislaus Sylvan Union SD 12/13-2 Err:520 $ 62,513 $ 25,005 $ 37,508
202 Stanislaus Sylvan Union SD 12/13-3 Err:520 $ 69,342 $ 27,737 $ 41,605
203 Stanislaus Sylvan Union SD 11/12-4 Err:520 $ 113,053 $ 45,221 $ 67,832 $ - ### $ -
204 Sylvan Union SD Total $ 622,361 $ 248,944 $ 373,417 $ 395,305 $ 158,122 $ (237,183) $ 11,761 0.26% $ 2,022 $ 9,739 $ 21.86 $ 200.78 $ 24.83
205 Stanislaus Tracy Joint USD 10/11-1 Err:520 $ 192,212 $ - ### $ -
206 Stanislaus Tracy Joint USD 10/11-2C-1 Err:520 $ 207,252 $ 82,901 $ 124,351 $ - ### $ -
207 Stanislaus Tracy Joint USD 10/11-3 Err:520 $ 327,027 $ 130,811 $ 196,216 $ - ### $ -
208 Stanislaus Tracy Joint USD 10/11-4C-1 Err:520 $ 186,598 $ 74,639 $ 111,959 $ - ### $ -
209 Tracy Joint USD Total* $ 913,089 $ 288,351 $ 432,526 $ - $ - $ - $ 288,351 6.44% $ 49,582 $ 238,769 $ 535.88 $ 4,922.66 $ 608.84
210 Stanislaus Tracy USD 11/12-1 Err:520 $ 226,151 $ 90,460 $ 135,691 $ - ### $ -
211 Stanislaus Tracy USD 11/12-2 Err:520 $ 204,659 $ 81,864 $ 122,795 $ - ### $ -
212 Stanislaus Tracy USD 11/12-3 Err:520 $ 198,503 $ 79,401 $ 119,102 $ - ### $ -
213 Stanislaus Tracy USD 11/12-4 Err:520 $ 163,954 $ 65,582 $ 98,372 $ - ### $ -
214 Tracy USD Total* $ 793,267 $ 317,307 $ 475,960 $ - $ - $ - $ 317,307 7.09% $ 54,562 $ 262,745 $ 589.69 $ 5,416.99 $ 669.98
215 Stanislaus Tuolumne COE 11/12-2 Err:520 $ - $ - $ - ### $ -
216 Stanislaus Tuolumne COE 10/11-3 2013-Q2 $ - $ - ### $ 27,753 $ 27,753 $ -
217 Tuolumne COE Total $ - $ - $ - $ 27,753 $ 27,753 $ - $ -
218 Stanislaus Turlock USD 11/12-1 Err:520 $ 327,247 $ 81,812 $ 245,435 $ - ### $ -
219 Stanislaus Turlock USD 11/12-2 Err:520 $ 316,303 $ 79,076 $ 237,227 $ - ### $ -
220 Stanislaus Turlock USD 10/11-3 2013-Q2 $ - $ - ### $ 674,325 $ 168,581 $ (505,744)
221 Stanislaus Turlock USD 11/12-3 Err:520 $ 320,440 $ 80,110 $ 240,330 $ - ### $ -
222 Stanislaus Turlock USD 10/11-4 Err:520 $ 926,251 $ 231,563 $ 694,688 $ - ### $ -
223 Stanislaus Turlock USD 11/12-4 Err:520 $ 262,616 $ 65,654 $ 196,962 $ - ### $ -
224 Turlock USD Total $ 2,152,857 $ 538,215 $ 1,614,642 $ 674,325 $ 168,581 $ (505,744) $ 32,471 0.73% $ 5,583 $ 26,888 $ 60.34 $ 554.34 $ 68.56
225 Stanislaus Vallecito Union SD 11/12-3 Err:520 $ 27,525 $ 19,268 $ 8,257 $ - ### $ -
226 Vallecito Union SD Total $ 27,525 $ 19,268 $ 8,257 $ - $ - $ - $ 19,268 0.43% $ 3,313 $ 15,955 $ 35.81 $ 328.94 $ 40.68
227 Stanislaus Waterford USD 10/11-2 2013-Q1 $ - $ - ### $ 62,392 $ 24,957 $ (37,435)
228 Stanislaus Waterford USD 12/13-1 Err:520 $ 10,213 $ 9,192 $ 1,021
229 Stanislaus Waterford USD 12/13-2 Err:520 $ 3,085 $ 2,777 $ 308
230 Stanislaus Waterford USD 12/13-3 Err:520 $ 2,138 $ 1,924 $ 214
231 Stanislaus Waterford USD 12/13-4 Err:520 $ 560 $ 504 $ 56
232 Stanislaus Waterford USD 13/14-1 Err:520 $ 1,319 $ 1,187 $ 132
233 Stanislaus Waterford USD 13/14-2 Err:520 $ 3,546 $ 3,191 $ 355
234 Stanislaus Waterford USD 11/12-2 Err:520 $ 52,488 $ 20,995 $ 31,493 $ - ### $ -
235 Waterford USD Total $ 73,349 $ 39,770 $ 33,579 $ 62,392 $ 24,957 $ (37,435) $ 2,335 0.05% $ 402 $ 1,933 $ 4.34 $ 39.86 $ 4.93
236 Grand Total Stanislaus LEC Err:502 Err:502 Err:502 $ 6,587,475 $ 2,924,082 $ (3,633,492) Err:502 100% $ 769,904 $ 3,707,547 $ 8,321 $ 76,438 $ 9,454
237 The sum of Column N equals the sum of "Column K" (Net Total) minus
238 the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
239 Column A County - Reporting LEC/LGA
240 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12 Pro-Rata Table
241 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Full check amount Check Total $ 769,906 <-- Enter check total here
242 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed has not been received Sum of Net Green $ 4,477,451
243 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment Sum of Net Red $ (94,213)
244 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
245 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
246 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
247 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
248 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
249 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
A B C D E F G H I J K L M N O P Q R

Total amount
2 Amount to be recouped withheld (FFY
Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Pro Rata Amount to release to 2013 and CUs in Option (insert 1 Modesto Jr. College -
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) Percent claiming unit Red) or 2) Hughson USD Lammersville ESD Yosemite CCD
250 The last subtotal amount is the final amount due to/from the LEC/LGA
251 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
252 Column N The sum of Column N equals the sum of "Column K" (Net Total) minus the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
253 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
254 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
255 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
256

257 Released Claiming Unit Invoice on placeholder to be paid 100%


258

259 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
260 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
261

262 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
263 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
264 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
265 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
266

267 Claiming units no longer participating (5% reduction)


268
269 12/13 claims
270 13/14 claims
A B C D E F G H I J K L M N O P Q R S T U V W
Submitted for Settlement Amount for Unpaid Total amount
1 Period of Service Payment Original Unpaid Placeholders Due to LEC/LGA(75% & Original Paid Deferred Settlement Amount Net (Column F + Column Amount to release to withheld (FFY Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount 40%) Amount to be released Amount for Paid Deferred Amount to be recouped from paid deferred claims J) Pro Rata Percent claiming unit 2013) or 2)
2 Sutter Auburn Union ESD 11/12-3 Err:520 $ 27,722 $ 25,000 $ 2,722 $ - ### $ - 2
3 Auburn Union ESD Total $ 27,722 $ 25,000 $ 2,722 $ - $ - $ - $ 25,000 1.04% $ 8,235 $ 16,765
4 Sutter Brittan ESD 11/12-2 Err:520 $ 26,254 $ 18,378 $ 7,876 $ - ### $ - 1
5 Brittan ESD Total $ 26,254 $ 18,378 $ 7,876 $ - $ - $ - $ 18,378 0.77% $ 6,054 $ 12,324
6 Sutter Buckeye Union ESD 11/12-1 Err:520 $ 26,051 $ 25,000 $ 1,051 $ - ### $ - 2
7 Sutter Buckeye Union ESD 11/12-2 Err:520 $ 26,503 $ 25,000 $ 1,503 $ - ### $ - 2
8 Sutter Buckeye Union ESD 10/11-3 2013-Q2 $ 25,252 $ 25,000 $ (252) 2
9 Sutter Buckeye Union ESD 11/12-3 Err:520 $ 29,000 $ 25,000 $ 4,000 $ - ### $ - 2
10 Sutter Buckeye Union ESD 11/12-4 Err:520 $ 41,337 $ 31,003 $ 10,334 $ - ### $ - 2
11 Buckeye Union ESD Total $ 122,891 $ 106,003 $ 16,888 $ 25,252 $ 25,000 $ (252) $ 105,751 4.41% $ 34,835 $ 70,916
12 Sutter Center JUSD 10/11-1 2012-Q4 $ - $ - ### $ 37,730 $ 28,298 $ (9,432) 2
13 Sutter Center JUSD 11/12-1 Err:520 $ 46,509 $ 34,882 $ 11,627 $ - ### $ - 2
14 Sutter Center JUSD 10/11-2 Err:520 $ 55,186 $ 22,074 $ 33,112 $ - ### $ -
15 Sutter Center JUSD 11/12-2 Err:520 $ 43,167 $ 32,375 $ 10,792 $ - ### $ - 2
16 Sutter Center JUSD 10/11-3 Err:520 $ 41,031 $ 30,773 $ 10,258 $ - ### $ - 2
17 Sutter Center JUSD 11/12-3 Err:520 $ 38,192 $ 28,644 $ 9,548 $ - ### $ - 2
18 Sutter Center JUSD 10/11-4 Err:520 $ 50,067 $ 20,027 $ 30,040 $ - ### $ -
19 Sutter Center JUSD 11/12-4 Err:520 $ 55,314 $ 22,126 $ 33,188 $ - ### $ -
20 Center JUSD Total $ 329,466 $ 190,901 $ 138,565 $ 37,730 $ 28,298 $ (9,432) $ 181,469 7.56% $ 59,777 $ 121,692
21 Sutter Colusa USD 11/12-2 2014-Q1 $ - $ - ### $ 29,996 $ 29,996 $ -
22 Sutter Colusa USD 10/11-3 2013-Q2 $ - $ - ### $ 26,607 $ 26,607 $ -
23 Sutter Colusa USD 10/11-4 2013-Q3 $ - $ - ### $ 28,603 $ 28,603 $ -
24 Colusa USD Total $ - $ - $ - $ 85,206 $ 85,206 $ - $ -
25 Sutter El Dorado COE 10/11-1 2012-Q4 $ - $ - ### $ 85,954 $ 85,954 $ -
26 Sutter El Dorado COE 10/11-2 2013-Q1 $ - $ - ### $ 87,589 $ 87,589 $ -
27 Sutter El Dorado COE 11/12-2 Err:520 $ - $ - $ - ### $ -
28 Sutter El Dorado COE 10/11-3 2013-Q2 $ - $ - ### $ 94,238 $ 94,238 $ -
29 Sutter El Dorado COE 10/11-4 2013-Q3 $ - $ - ### $ 91,587 $ 91,587 $ -
30 Sutter El Dorado COE 11/12-4 Err:520 $ - $ - $ - ### $ -
31 El Dorado COE Total $ - $ - $ - $ 359,368 $ 359,368 $ - $ -
32 Sutter El Dorado Union HSD 10/11-1 2012-Q4 $ - $ - ### $ 25,560 $ 25,000 $ (560) 2
33 Sutter El Dorado Union HSD 11/12-1 Err:520 $ 35,815 $ 26,861 $ 8,954 $ - ### $ - 2
34 Sutter El Dorado Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 28,320 $ 25,000 $ (3,320) 2
35 Sutter El Dorado Union HSD 11/12-2 Err:520 $ 25,945 $ 25,000 $ 945 $ - ### $ - 2
36 Sutter El Dorado Union HSD 11/12-3 Err:520 $ 27,680 $ 25,000 $ 2,680 $ - ### $ - 2
37 Sutter El Dorado Union HSD 11/12-4 Err:520 $ 28,393 $ 25,000 $ 3,393 $ - ### $ - 2
38 El Dorado Union HSD Total $ 117,833 $ 101,861 $ 15,972 $ 53,880 $ 50,000 $ (3,880) $ 97,981 4.08% $ 32,276 $ 65,705
39 Sutter Elk Grove USD 10/11-1 2012-Q4 $ - $ - ### $ 99,344 $ 39,738 $ (59,606)
40 Sutter Elk Grove USD 11/12-1 Err:520 $ 139,463 $ 55,785 $ 83,678 $ - ### $ -
41 Sutter Elk Grove USD 10/11-2 2013-Q1 $ - $ - ### $ 125,421 $ 50,168 $ (75,253)
42 Sutter Elk Grove USD 11/12-2 Err:520 $ 103,246 $ 41,298 $ 61,948 $ - ### $ -
43 Sutter Elk Grove USD 10/11-3 2013-Q2 $ - $ - ### $ 103,929 $ 41,572 $ (62,357)
44 Sutter Elk Grove USD 11/12-3 Err:520 $ 113,727 $ 45,491 $ 68,236 $ - ### $ -
45 Sutter Elk Grove USD 10/11-4 Err:520 $ 109,292 $ 43,717 $ 65,575 $ - ### $ -
46 Sutter Elk Grove USD 11/12-4 Err:520 $ 108,919 $ 43,568 $ 65,351 $ - ### $ -
47 Elk Grove USD Total $ 574,647 $ 229,859 $ 344,788 $ 328,694 $ 131,478 $ (197,216) $ 32,643 1.36% $ 10,753 $ 21,890
48 Sutter Eureka Union SD 10/11-3C1 Err:520 $ 31,996 $ 22,397 $ 9,599 $ - ### $ -
49 Sutter Eureka Union SD 10/11-4C-1 Err:520 $ 27,648 $ 19,354 $ 8,294 $ - ### $ -
50 Eureka Union SD Total* $ 59,644 $ 41,751 $ 17,893 $ - $ - $ - $ 41,751 1.74% $ 13,753 $ 27,998
51 Sutter Galt Joint Union SD 11/12-3 Err:520 $ 26,288 $ 25,000 $ 1,288 $ - ### $ - 2
52 Sutter Galt Joint Union SD 10/11-3C1 Err:520 $ 41,587 $ 31,190 $ 10,397 $ - ### $ -
53 Sutter Galt Joint Union SD 10/11-2 2013-Q1 $ - $ - ### $ 45,413 $ 34,060 $ (11,353)
54 Sutter Galt Joint Union SD 10/11-1 Err:520 $ 40,535 $ - ### $ - Adjust all claims when funding available
55 Sutter Galt Joint Union SD 10/11-4C-1 Err:520 $ 40,161 $ 30,121 $ 10,040 $ - ### $ - 13624 Overcollection. Was marked as dicontinuing claiming unit
56 Galt Joint Union SD Total* $ 148,571 $ 86,311 $ 21,725 $ 45,413 $ 34,060 $ (11,353) $ 74,958 3.12% $ 24,692 $ 50,266 11353
57 Sutter Grass Valley ESD 10/11-1 Err:520 $ 28,128 $ - ### $ - 2 2271
58 Sutter Grass Valley ESD 11/12-2 Err:520 $ 26,503 $ 25,000 $ 1,503 $ - ### $ - 2
59 Sutter Grass Valley ESD 11/12-3 Err:520 $ 27,539 $ 25,000 $ 2,539 $ - ### $ - 2
60 Sutter Grass Valley ESD 10/11-4 Err:520 $ 26,089 $ 25,000 $ 1,089 $ - ### $ - 2
61 Sutter Grass Valley ESD 11/12-4 Err:520 $ 30,566 $ 25,000 $ 5,566 $ - ### $ - 2
62 Grass Valley ESD Total $ 138,825 $ 100,000 $ 10,697 $ - $ - $ - $ 100,000 4.17% $ 32,941 $ 67,059
63 Sutter Live Oak USD 10/11-1 2012-Q4 $ - $ - ### $ 39,598 $ 29,699 $ (9,899) 2
64 Sutter Live Oak USD 10/11-2 2013-Q1 $ - $ - ### $ 57,526 $ 23,010 $ (34,516)
65 Sutter Live Oak USD 11/12-1 Err:520 $ 31,982 $ 25,000 $ 6,982 $ - ### $ - 2
66 Sutter Live Oak USD 11/12-2 Err:520 $ 40,110 $ 30,083 $ 10,027 $ - ### $ - 2
67 Sutter Live Oak USD 10/11-4C-1 Err:520 $ 54,438 $ 21,775 $ 32,663 $ - ### $ -
68 Sutter Live Oak USD 11/12-3 Err:520 $ 41,044 $ 30,783 $ 10,261 $ - ### $ - 2
69 Sutter Live Oak USD 11/12-4 Err:520 $ 41,855 $ 31,391 $ 10,464 $ - ### $ - 2
70 Sutter Live Oak USD 10/11-3C1 Err:520 $ 43,932 $ 32,949 $ 10,983 $ - ### $ - 2
71 Live Oak USD Total* $ 253,361 $ 171,981 $ 81,380 $ 97,124 $ 52,709 $ (44,415) $ 127,566 5.31% $ 42,021 $ 85,545
72 Sutter Loomis Union ESD 10/11-1-C1 Err:520 $ 48,757 $ - ### $ - 2
73 Sutter Loomis Union ESD 11/12-1 Err:520 $ 30,587 $ 25,000 $ 5,587 $ - ### $ - 2
74 Sutter Loomis Union ESD 10/11-2 Err:520 $ 71,975 $ 28,790 $ 43,185 $ - ### $ -
75 Sutter Loomis Union ESD 11/12-2 Err:520 $ 25,527 $ 25,000 $ 527 $ - ### $ - 2
76 Sutter Loomis Union ESD 10/11-3-C1 Err:520 $ 83,013 $ 33,205 $ 49,808 $ - ### $ -
77 Sutter Loomis Union ESD 10/11-4C-1 Err:520 $ 51,574 $ 20,630 $ 30,944 $ - ### $ -
78 Loomis Union ESD Total $ 311,433 $ 132,625 $ 130,051 $ - $ - $ - $ 132,625 5.52% $ 43,688 $ 88,937
79 Sutter Marysville JUSD 10/11-3 2013-Q2 $ - $ - ### $ 28,954 $ 28,954 $ -
80 Sutter Marysville JUSD 11/12-4 Err:520 $ - $ - $ - ### $ -
81 Marysville JUSD Total $ - $ - $ - $ 28,954 $ 28,954 $ - $ -
82 Sutter Mother Lode Union ESD 11/12-2 Err:520 $ 26,231 $ 18,362 $ 7,869 $ - ### $ -
83 Mother Lode Union ESD Total $ 26,231 $ 18,362 $ 7,869 $ - $ - $ - $ 18,362 0.76% $ 6,049 $ 12,313
84 Sutter Natomas USD 11/12-1 Err:520 $ 109,651 $ 43,860 $ 65,791 $ - ### $ -
85 Sutter Natomas USD 11/12-2 Err:520 $ 144,263 $ 57,705 $ 86,558 $ - ### $ -
86 Sutter Natomas USD 11/12-3 Err:520 $ 127,286 $ 50,914 $ 76,372 $ - ### $ -
87 Sutter Natomas USD 11/12-4 Err:520 $ 89,597 $ 35,839 $ 53,758 $ - ### $ -
88 Sutter Natomas USD 10/11-1-C1 Err:520 $ 73,860 $ - ### $ -
89 Sutter Natomas USD 10/11-2-C1 Err:520 $ 105,476 $ 42,190 $ 63,286 $ - ### $ -
90 Sutter Natomas USD 10/11-3C1 Err:520 $ 93,979 $ 37,592 $ 56,387 $ - ### $ -
91 Sutter Natomas USD 10/11-4C-1 Err:520 $ 70,962 $ 28,385 $ 42,577 $ - ### $ -
92 Natomas USD Total $ 815,074 $ 296,485 $ 444,729 $ - $ - $ - $ 296,485 12.35% $ 97,665 $ 198,820
93 Sutter Nevada County SOS 10/11-1 2012-Q4 $ - $ - ### $ 37,606 $ 28,205 $ (9,401) 2
94 Sutter Nevada County SOS 11/12-1 Err:520 $ 26,891 $ 25,000 $ 1,891 $ - ### $ - 2
95 Sutter Nevada County SOS 10/11-2 2013-Q1 $ - $ - ### $ 33,637 $ 25,228 $ (8,409)
96 Sutter Nevada County SOS 11/12-2 Err:520 $ 34,296 $ 25,722 $ 8,574 $ - ### $ - 2
97 Sutter Nevada County SOS 10/11-3 2013-Q2 $ - $ - ### $ 30,432 $ 25,000 $ (5,432) 2
98 Sutter Nevada County SOS 11/12-3 Err:520 $ 31,197 $ 25,000 $ 6,197 $ - ### $ - 2
99 Sutter Nevada County SOS 10/11-4 2013-Q3 $ - $ - ### $ 41,969 $ 31,477 $ (10,492) 2
100 Sutter Nevada County SOS 11/12-4 Err:520 $ 38,802 $ 29,102 $ 9,700 $ - ### $ - 2
101 Nevada County SOS Total $ 131,186 $ 104,824 $ 26,362 $ 143,644 $ 109,910 $ (33,734) $ 71,090 2.96% $ 23,418 $ 47,672
102 Sutter Placer COE 10/11-1 2012-Q4 $ - $ - ### $ 178,748 $ 71,499 $ (107,249)
103 Sutter Placer COE 11/12-1 Err:520 $ 154,015 $ 61,606 $ 92,409 $ - ### $ -
104 Sutter Placer COE 10/11-2 2013-Q1 $ - $ - ### $ 166,248 $ 66,499 $ (99,749)
105 Sutter Placer COE 11/12-2 Err:520 $ 118,554 $ 47,422 $ 71,132 $ - ### $ -
106 Sutter Placer COE 10/11-3 2013-Q2 $ - $ - ### $ 222,919 $ 89,168 $ (133,751)
107 Sutter Placer COE 11/12-3 Err:520 $ 161,209 $ 64,484 $ 96,725 $ - ### $ -
108 Sutter Placer COE 10/11-4 Err:520 $ 184,717 $ 73,887 $ 110,830 $ - ### $ -
109 Sutter Placer COE 12/13-1 Err:520 $ 85,936 $ 34,374 $ 51,562
110 Sutter Placer COE 12/13-2 Err:520 $ 77,693 $ 31,077 $ 46,616
111 Sutter Placer COE 11/12-4 Err:520 $ 117,568 $ 47,027 $ 70,541 $ - ### $ -
112 Placer COE Total $ 899,692 $ 359,877 $ 539,815 $ 567,915 $ 227,166 $ (340,749) $ 19,128 0.80% $ 6,301 $ 12,827
113 Sutter Placer Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 37,719 $ 37,719 $ -
114 Placer Union HSD Total $ - $ - $ - $ 37,719 $ 37,719 $ - $ -
115 Sutter Placerville Union SD 11/12-1 Err:520 $ 68,606 $ 27,442 $ 41,164 $ - ### $ -
116 Sutter Placerville Union SD 11/12-2 Err:520 $ 90,297 $ 36,119 $ 54,178 $ - ### $ -
117 Sutter Placerville Union SD 11/12-3 Err:520 $ 88,299 $ 35,320 $ 52,979 $ - ### $ -
118 Sutter Placerville Union SD 11/12-4 Err:520 $ 59,749 $ 23,900 $ 35,849 $ - ### $ -
119 Sutter Placerville USD 10/11-1-C1 Err:520 $ 52,127 $ - ### $ -
120 Sutter Placerville USD 10/11-2-C1 Err:520 $ 65,683 $ 26,273 $ 39,410 $ - ### $ -
121 Sutter Placerville Union SD 10/11-3C1 Err:520 $ 75,976 $ 30,390 $ 45,586 $ - ### $ -
122 Sutter Placerville Union SD 10/11-4C-1 Err:520 $ 50,817 $ 20,327 $ 30,490 $ - ### $ -
123 Placerville Union SD Total* $ 551,554 $ 199,771 $ 299,656 $ - $ - $ - $ 199,771 8.32% $ 65,806 $ 133,965
A B C D E F G H I J K L M N O P Q R S T U V W
Submitted for Settlement Amount for Unpaid Total amount
1 Period of Service Payment Original Unpaid Placeholders Due to LEC/LGA(75% & Original Paid Deferred Settlement Amount Net (Column F + Column Amount to release to withheld (FFY Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount 40%) Amount to be released Amount for Paid Deferred Amount to be recouped from paid deferred claims J) Pro Rata Percent claiming unit 2013) or 2)
124 Sutter Pollock Pines ESD 11/12-4 Err:520 $ - $ - $ - ### $ -
125 Pollock Pines ESD Total $ - $ - $ - $ - $ - $ - $ -
126 Sutter Rescue Union ESD 10/11-2 2013-Q1 $ - $ - ### $ 27,899 $ 27,899 $ -
127 Sutter Rescue Union ESD 11/12-2 Err:520 $ - $ - $ - ### $ -
128 Sutter Rescue Union ESD 11/12-3 Err:520 $ 27,567 $ 27,567 $ - $ - ### $ -
129 Sutter Rescue Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 27,899 ### $ -
130 Rescue Union ESD Total $ 27,567 $ 27,567 $ - $ 55,798 $ 55,798 $ - $ 27,567 1.15% $ 9,081 $ 18,486
131 Sutter Robla ESD 10/11-1 Err:520 $ 32,279 $ - ### $ - 2
132 Sutter Robla ESD 10/11-3 Err:520 $ 40,335 $ 28,235 $ 12,100 $ - ### $ - 2
133 Sutter Robla ESD 11/12-3 Err:520 $ 39,329 $ 27,530 $ 11,799 $ - ### $ - 2
134 Sutter Robla ESD 10/11-4 Err:520 $ 39,029 $ 27,320 $ 11,709 $ - ### $ - 2
135 Robla ESD Total $ 150,972 $ 83,085 $ 35,608 $ - $ - $ - $ 83,085 3.46% $ 27,369 $ 55,716
136 Sutter Roseville City ESD 10/11-1 2012-Q4 $ - $ - ### $ 40,326 $ 30,245 $ (10,081) 2
137 Sutter Roseville City ESD 11/12-1 Err:520 $ 40,861 $ 30,646 $ 10,215 $ - ### $ - 2
138 Sutter Roseville City ESD 10/11-2 2013-Q1 $ - $ - ### $ 38,619 $ 28,964 $ (9,655) 2
139 Sutter Roseville City ESD 11/12-2 Err:520 $ 35,517 $ 26,638 $ 8,879 $ - ### $ - 2
140 Sutter Roseville City ESD 10/11-3 Err:520 $ 59,847 $ 23,939 $ 35,908 $ - ### $ -
141 Sutter Roseville City ESD 11/12-3 Err:520 $ 86,809 $ 34,724 $ 52,085 $ - ### $ -
142 Sutter Roseville City ESD 10/11-4 Err:520 $ 48,267 $ 36,200 $ 12,067 $ - ### $ - 2
143 Sutter Roseville City ESD 11/12-4 Err:520 $ 52,684 $ 21,074 $ 31,610 $ - ### $ -
144 Roseville City ESD Total $ 323,985 $ 173,221 $ 150,764 $ 78,945 $ 59,209 $ (19,736) $ 153,485 6.39% $ 50,559 $ 102,926
145 Sutter Roseville Joint UHSD 11/12-2 Err:520 $ 30,780 $ 25,000 $ 5,780 $ - ### $ - 2
146 Sutter Roseville Joint UHSD 11/12-3 Err:520 $ 33,494 $ 25,121 $ 8,373 $ - ### $ - 2
147 Sutter Roseville Joint UHSD 11/12-1C-1 Err:520 $ 42,574 $ 31,931 $ 10,643 $ - ### $ - 2
148 Roseville Joint UHSD Total $ 106,848 $ 82,052 $ 24,796 $ - $ - $ - $ 82,052 3.42% $ 27,029 $ 55,023
149 Sutter Sacramento COE 10/11-1 2012-Q4 $ - $ - ### $ 156,077 $ 62,431 $ (93,646)
150 Sutter Sacramento COE 11/12-1 Err:520 $ 60,556 $ 24,222 $ 36,334 $ - ### $ -
151 Sutter Sacramento COE 10/11-2 Err:520 $ 100,772 $ 40,309 $ 60,463 $ - ### $ -
152 Sutter Sacramento COE 11/12-2 Err:520 $ 65,299 $ 26,120 $ 39,179 $ - ### $ -
153 Sutter Sacramento COE 10/11-3 Err:520 $ 97,551 $ 39,020 $ 58,531 $ - ### $ -
154 Sutter Sacramento COE 11/12-3 Err:520 $ 55,157 $ 22,063 $ 33,094 $ - ### $ -
155 Sutter Sacramento COE 10/11-4 Err:520 $ 96,029 $ 38,412 $ 57,617 $ - ### $ -
156 Sutter Sacramento COE 11/12-4 Err:520 $ 55,533 $ 22,213 $ 33,320 $ - ### $ -
157 Sacramento COE Total* $ 530,897 $ 212,359 $ 318,538 $ 156,077 $ 62,431 $ (93,646) $ 118,713 4.95% $ 39,105 $ 79,608
158 Sutter Sutter County SOS - Staff 11/12-1 Err:520 $ 60,486 $ 24,194 $ 36,292 $ - ### $ -
159 Sutter Sutter County SOS - Staff 10/11-2 2013-Q1 $ - $ - ### $ 83,391 $ 33,356 $ (50,035)
160 Sutter Sutter County SOS - Staff 10/11-1 2012-Q4 $ - $ - ### $ 64,134 $ 25,654 $ (38,480)
161 Sutter Sutter County SOS - Staff 10/11-4 2013-Q3 $ - $ - ### $ 95,939 $ 38,376 $ (57,563)
162 Sutter Sutter County SOS - Staff 11/12-2 Err:520 $ 51,449 $ 20,580 $ 30,869 $ - ### $ -
163 Sutter Sutter County SOS - Staff 10/11-3 2013-Q2 $ - $ - ### $ 63,596 $ 25,438 $ (38,158)
164 Sutter Sutter County SOS - Staff 11/12-3 Err:520 $ 52,597 $ 21,039 $ 31,558 $ - ### $ -
165 Sutter Sutter County SOS - Staff 12/13-1 Err:520 $ 36,184 $ 27,138 $ 9,046
166 Sutter Sutter County SOS - Staff 12/13-2 Err:520 $ 35,324 $ 26,493 $ 8,831
167 Sutter Sutter County SOS - Staff 12/13-3 Err:520 $ 31,235 $ 23,426 $ 7,809
168 Sutter Sutter County SOS - Staff 12/13-4 Err:520 $ 40,010 $ 30,008 $ 10,002
169 Sutter Sutter County SOS - Staff 11/12-4 Err:520 $ 59,072 $ 23,629 $ 35,443 $ - ### $ -
170 Sutter County SOS - Staff Total* $ 366,357 $ 196,507 $ 169,850 $ 307,060 $ 122,824 $ (184,236) $ 12,271 0.51% $ 4,042 $ 8,229
171 Sutter Tahoe-Truckee Joint Unified 10/11-1 2012-Q4 $ - $ - ### $ 28,213 $ 25,000 $ (3,213) 2
172 Sutter Tahoe-Truckee Joint Unified 11/12-2 Err:520 $ 31,092 $ 25,000 $ 6,092 $ - ### $ - 2
173 Sutter Tahoe-Truckee Joint Unified 10/11-3 Err:520 $ 34,213 $ 25,660 $ 8,553 $ - ### $ - 2
174 Sutter Tahoe-Truckee Joint Unified 11/12-3 Err:520 $ 46,927 $ 35,195 $ 11,732 $ - ### $ - 2
175 Sutter Tahoe-Truckee Joint Unified 10/11-4 Err:520 $ 30,062 $ 25,000 $ 5,062 $ - ### $ - 2
176 Sutter Tahoe-Truckee Joint Unified 11/12-4 Err:520 $ 29,202 $ 25,000 $ 4,202 $ - ### $ - 2
177 Tahoe-Truckee Joint Unified Total $ 171,496 $ 135,855 $ 35,641 $ 28,213 $ 25,000 $ (3,213) $ 132,642 5.53% $ 43,693 $ 88,949
178 Sutter Washington USD 10/11-1 2012-Q4 $ - $ - ### $ 34,946 $ 26,210 $ (8,736) 2
179 Sutter Washington USD 10/11-2 2013-Q1 $ - $ - ### $ 40,602 $ 30,452 $ (10,150) 2
180 Sutter Washington USD 10/11-3 2013-Q2 $ - $ - ### $ 32,333 $ 25,000 $ (7,333) 2
181 Sutter Washington USD 11/12-3 Err:520 $ 35,036 $ 26,277 $ 8,759 $ - ### $ - 2
182 Sutter Washington USD 10/11-4 Err:520 $ 37,504 $ 28,128 $ 9,376 $ - ### $ - 2
183 Sutter Washington USD 11/12-4 Err:520 $ 35,529 $ 26,647 $ 8,882 $ - ### $ - 2
184 Washington USD Total $ 108,069 $ 81,052 $ 27,017 $ 107,881 $ 81,662 $ (26,219) $ 54,833 2.28% $ 18,062 $ 36,771
185 Sutter Western Placer USD 11/12-1 Err:520 $ 32,776 $ 25,000 $ 7,776 $ - ### $ - 2
186 Sutter Western Placer USD 10/11-2 2013-Q1 $ - $ - ### $ 28,666 $ 25,000 $ (3,666) 2
187 Sutter Western Placer USD 11/12-2 Err:520 $ 29,051 $ 25,000 $ 4,051 $ - ### $ - 2
188 Sutter Western Placer USD 10/11-3 2013-Q2 $ - $ - ### $ 59,178 $ 23,671 $ (35,507)
189 Sutter Western Placer USD 11/12-3 Err:520 $ 59,816 $ 23,926 $ 35,890 $ - ### $ -
190 Sutter Western Placer USD 10/11-4 2013-Q3 $ - $ - ### $ 39,854 $ 29,891 $ (9,963) 2
191 Sutter Western Placer USD 11/12-4 Err:520 $ 37,498 $ 28,124 $ 9,374 $ - ### $ -
192 Sutter Western Placer USD 10/11-1C-1 2012-Q4 $ - $ - ### $ 56,474 $ 22,590 $ (33,884)
193 Western Placer USD Total $ 159,141.00 $ 102,050.00 $ 57,091.00 $ 184,172 $ 101,152 $ (83,020) $ 19,030 0.79% $ 6,269 $ 12,761
194 Sutter Wheatland ESD 11/12-2 2014-Q1 $ - $ - ### $ - $ -
195 Wheatland ESD Total $ - $ - $ - $ - $ - $ - $ -
196 Sutter Woodland JUSD 10/11-2 2013-Q1 $ - $ - ### $ 28,892 $ 25,000 $ (3,892) 2
197 Sutter Woodland JUSD 10/11-3 2013-Q2 $ - $ - ### $ 28,457 $ 25,000 $ (3,457) 2
198 Sutter Woodland JUSD 10/11-4 Err:520 $ 33,896 $ 25,422 $ 8,474 $ - ### $ - 2
199 Woodland JUSD Total $ 33,896 $ 25,422 $ 8,474 $ 57,349 $ 50,000 $ (7,349) $ 18,073 0.75% $ 5,953 $ 12,120
200 Sutter Yolo Co. Supt. of Schools 10/11-1 2012-Q4 $ - $ - ### $ 29,969 $ 25,000 $ (4,969) 2
201 Sutter Yolo Co. Supt. Of Schools 10/11-2 Err:520 $ 34,623 $ 25,967 $ 8,656 $ - ### $ - 2
202 Sutter Yolo Co. Supt. of Schools 10/11-4 Err:520 $ 26,438 $ 25,000 $ 1,438 $ - ### $ - 2
203 Yolo Co. Supt. of Schools Total $ 61,061 $ 50,967 $ 10,094 $ 29,969 $ 25,000 $ (4,969) $ 45,998 1.92% $ 15,152 $ 30,846
204 Sutter Yuba City USD 11/12-2 Err:520 $ 25,807 $ 25,000 $ 807 $ - ### $ - 2
205 Sutter Yuba City USD 10/11-1-C1 Err:520 $ 31,838 $ - ### $ - 2
206 Sutter Yuba City USD 10/11-2-C1 Err:520 $ 53,383 $ 21,353 $ 32,030 $ - ### $ -
207 Sutter Yuba City USD 10/11-3C1 Err:520 $ 48,972 $ 36,729 $ 12,243 $ - ### $ - 2
208 Sutter Yuba City USD 10/11-4C-1 Err:520 $ 35,637 $ 26,728 $ 8,909 $ - ### $ - 2
209 Yuba City USD Total $ 195,637 $ 109,810 $ 53,989 $ - $ - $ - $ 109,810 4.57% $ 36,172 $ 73,638
210 Grand Total Sutter LEC Err:502 Err:502 Err:502 $ 2,816,363 $ 1,752,944 $ (1,063,419) Err:502 100.00% $ 790,750 $ 1,609,767
211 The sum of Column N equals the sum of "Column K" (Net Total) minus
212 the sum of "Net Red" (Pro Rata Table) minus the "Check Total" (Pro Rata Table)
213 Column A County - Reporting LEC/LGA
214 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12 Pro-Rata Table
215 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number Full check amount Check Total $ 790,751 <-- Enter check total here
216 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed has not been received Sum of Net Green $ 2,400,517
217 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment Sum of Net Red $ -
218 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
219 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
220 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
221 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
222 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
223 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
224 The last subtotal amount is the final amount due to/from the LEC/LGA
225 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
226

227 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
228 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
229 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
230

231 Released
Claiming Unit Invoice on placeholder to be paid 100%
232

233 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
234 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
235
A B C D E F G H I J K L M N O P Q R S T U V W
Submitted for Settlement Amount for Unpaid Total amount
1 Period of Service Payment Original Unpaid Placeholders Due to LEC/LGA(75% & Original Paid Deferred Settlement Amount Net (Column F + Column Amount to release to withheld (FFY Option (insert 1
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount 40%) Amount to be released Amount for Paid Deferred Amount to be recouped from paid deferred claims J) Pro Rata Percent claiming unit 2013) or 2)
236 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
237 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
238 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
239 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
240

241 Claiming units no longer participating (5% reduction)


242
243 12/13 claims
244 13/14 claims
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
2 Tulare LGA Burton ESD 10/11-1 2012-Q4 $ - $ - ### $ 48,186 $ 36,140 $ (12,046) 2
3 Tulare LGA Burton ESD 11/12-1 Err:520 $ 34,911 $ 26,183 $ 8,728 $ - ### $ - 2 2180
4 Tulare LGA Burton ESD 10/11-2 2013-Q1 $ - $ - ### $ 39,960 $ 29,970 $ (9,990) 2
5 Tulare LGA Burton ESD 11/12-2 Err:520 $ 42,771 $ 32,078 $ 10,693 $ - ### $ - 2 2972
6 Tulare LGA Burton ESD 10/11-3 2013-Q2 $ - $ - ### $ 35,509 $ 26,632 $ (8,877) 2
7 Tulare LGA Burton ESD 11/12-3 Err:520 $ 30,866 $ 25,000 $ 5,866 $ - ### $ - 2 3770
8 Tulare LGA Burton ESD 10/11-4 2013-Q3 $ - $ - ### $ 41,429 $ 31,072 $ (10,357) 2
9 Tulare LGA Burton ESD 11/12-4C-1 Err:520 $ 34,641 $ 25,981 $ 8,660 $ - ### $ - 2 4544
10 Burton ESD Total $ 143,189 $ 109,242 $ 33,947 $ 165,084 $ 123,814 $ (41,270) $ 67,972
11 Tulare LGA College of the Sequoias 10/11-1 2012-Q4 $ - $ - ### $ 51,267 $ 17,943 $ (33,324)
12 Tulare LGA College of the Sequoias 11/12-1 Err:520 $ 46,080 $ 32,256 $ 13,824 $ - ### $ - 2181
13 Tulare LGA College of the Sequoias 10/11-2 2013-Q1 $ - $ - ### $ 54,413 $ 19,045 $ (35,368)
14 Tulare LGA College of the Sequoias 11/12-2 Err:520 $ 51,909 $ 18,168 $ 33,741 $ - ### $ - 2973
15 Tulare LGA College of the Sequoias 10/11-3 2013-Q2 $ - $ - ### $ 57,395 $ 20,088 $ (37,307)
16 Tulare LGA College of the Sequoias 11/12-3 Err:520 $ 32,152 $ 22,506 $ 9,646 $ - ### $ - 3773
17 Tulare LGA College of the Sequoias 10/11-4 2013-Q3 $ - $ - ### $ 61,832 $ 21,641 $ (40,191)
18 Tulare LGA College of the Sequoias 12/13-1 Err:520 $ 22,235 $ 22,235 $ - 5310
19 Tulare LGA College of the Sequoias 12/13-2 Err:520 $ 22,727 $ 22,727 $ - 6111
20 Tulare LGA College of the Sequoias 12/13-3 Err:520 $ 15,530 $ 15,530 $ - 6877
21 Tulare LGA College of the Sequoias 11/12-4C-1 Err:520 $ 38,259 $ 26,781 $ 11,478 $ - ### $ - 4545
22 College of the Sequoias Total $ 228,892 $ 160,203 $ 68,689 $ 224,907 $ 78,717 $ (146,190) $ 14,013
23 Tulare LGA Dinuba Unified 10/11-2 2013-Q1 $ - $ - ### $ 44,886 $ 31,420 $ (13,466)
24 Tulare LGA Dinuba Unified 11/12-2 Err:520 $ 30,925 $ 21,648 $ 9,277 $ - ### $ - 2974
25 Tulare LGA Dinuba Unified 10/11-3 2013-Q2 $ - $ - ### $ 37,962 $ 26,573 $ (11,389)
26 Tulare LGA Dinuba Unified 11/12-3 Err:520 $ 37,046 $ 25,932 $ 11,114 $ - ### $ - 3772
27 Tulare LGA Dinuba Unified 10/11-4 2013-Q3 $ - $ - ### $ 39,070 $ 27,349 $ (11,721)
28 Dinuba Unified Total $ 67,971.00 $ 47,580.00 $ 20,391.00 $ 121,918 $ 85,342 $ (36,576) $ 11,004
29 Tulare LGA Earlimart ESD 10/11-1 2012-Q4 $ - $ - ### $ 37,858 $ 28,394 $ (9,464) 2
30 Tulare LGA Earlimart ESD 11/12-2 Err:520 $ 33,773 $ 25,330 $ 8,443 $ - ### $ - 2 2975
31 Tulare LGA Earlimart ESD 10/11-3 2013-Q2 $ - $ - ### $ 28,707 $ 25,000 $ (3,707) 2
32 Tulare LGA Earlimart ESD 11/12-3 Err:520 $ 57,136 $ 22,854 $ 34,282 $ - ### $ - 3773
33 Tulare LGA Earlimart ESD 11/12-4 Err:520 $ 45,397 $ 34,048 $ 11,349 $ - ### $ - 2 4548
34 Tulare LGA Earlimart ESD 11/12-1 2013-Q4 $ 31,428 $ 25,000 $ 6,428 $ - ### $ - 2 2183
35 Earlimart ESD Total $ 167,734 $ 107,232 $ 60,502 $ 66,565 $ 53,394 $ (13,171) $ 94,061
36 Tulare LGA Exeter Union ESD 10/11-1 2012-Q4 $ - $ - ### $ 39,340 $ 29,505 $ (9,835) 2
37 Tulare LGA Exeter Union ESD 11/12-1 Err:520 $ 27,480 $ 25,000 $ 2,480 $ - ### $ - 2 2184
38 Tulare LGA Exeter Union ESD 10/11-2 2013-Q1 $ - $ - ### $ 43,557 $ 32,668 $ (10,889) 2
39 Tulare LGA Exeter Union ESD 11/12-2 Err:520 $ 27,390 $ 25,000 $ 2,390 $ - ### $ - 2 2977
40 Tulare LGA Exeter Union ESD 10/11-3 2013-Q2 $ - $ - ### $ 35,503 $ 26,627 $ (8,876) 2
41 Tulare LGA Exeter Union ESD 11/12-3 Err:520 $ 26,648 $ 25,000 $ 1,648 $ - ### $ - 2 3774
42 Tulare LGA Exeter Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 38,900 $ 29,175 $ (9,725) 2
43 Exeter Union ESD Total $ 81,518.00 $ 75,000.00 $ 6,518.00 $ 157,300 $ 117,975 $ (39,325) $ 35,675
44 Tulare LGA Porterville USD 10/11-1 2012-Q4 $ - $ - ### $ 39,325 $ 29,494 $ (9,831)
45 Tulare LGA Porterville USD 11/12-1 Err:520 $ 76,504 $ 30,602 $ 45,902 $ - ### $ - 2189
46 Tulare LGA Porterville USD 10/11-2 2013-Q1 $ - $ - ### $ 70,395 $ 28,158 $ (42,237)
47 Tulare LGA Porterville USD 11/12-2 Err:520 $ 69,127 $ 27,651 $ 41,476 $ - ### $ - 2983
48 Tulare LGA Porterville USD 10/11-3 2013-Q2 $ - $ - ### $ 58,686 $ 23,474 $ (35,212)
49 Tulare LGA Porterville USD 11/12-3 Err:520 $ 73,801 $ 29,520 $ 44,281 $ - ### $ - 3780
50 Tulare LGA Porterville USD 10/11-4 2013-Q3 $ - $ - ### $ 58,994 $ 23,598 $ (35,396)
51 Tulare LGA Porterville USD 12/13-1C-1 Err:520 $ 43,778 $ 32,834 $ 10,944 5320
52 Tulare LGA Porterville USD 11/12-4C-1 Err:520 $ 62,536 $ 25,014 $ 37,522 $ - ### $ - 4555
53 Porterville USD Total $ 325,746 $ 145,621 $ 180,125 $ 227,400 $ 104,724 $ (122,676) $ 22,945
54 Tulare LGA Strathmore Union ESD 10/11-3 2013-Q2 $ - $ - ### $ 30,003 $ 25,000 $ (5,003) 2
55 Tulare LGA Strathmore Union ESD 12/13-1 Err:520 $ 10,577 $ 9,519 $ 1,058 5322
56 Tulare LGA Strathmore Union ESD 12/13-2 Err:520 $ 13,266 $ 11,939 $ 1,327 6123
57 Tulare LGA Strathmore Union ESD 10/11-4 2013-Q3 $ - $ - ### $ 30,701 $ 25,000 $ (5,701) 2
58 Strathmore Union ESD Total $ 23,843.00 $ 21,458.00 $ 2,385.00 $ 60,704 $ 50,000 $ (10,704) $ 10,754
59 Tulare LGA Tulare City SD 11/12-1 2013-Q4 $ - $ - ### $ 74,081 $ 74,081 $ -
60 Tulare LGA Tulare City SD 10/11-2 2013-Q1 $ - $ - ### $ 61,170 $ 61,170 $ -
61 Tulare LGA Tulare City SD 10/11-3 2013-Q2 $ - $ - ### $ 70,538 $ 70,538 $ -
62 Tulare LGA Tulare City SD 10/11-4 2013-Q3 $ - $ - ### $ 74,502 $ 74,502 $ -
63 Tulare LGA Tulare City SD 11/12-4 Err:520 $ - $ - ### $ - ### $ -
64 Tulare City SD Total $ - $ - $ - $ 280,291 $ 280,291 $ - $ -
65 Tulare LGA Tulare COE - School Health Program 11/12-4 Err:520 $ - $ - $ - $ - ### $ -
66 Tulare COE - School Health Program Total $ - $ - $ - $ - $ - $ - $ -
67 Tulare LGA Tulare COE - Special Services Division 10/11-1 2012-Q4 $ - $ - ### $ 563,681 $ 225,472 $ (338,209)
68 Tulare LGA Tulare COE - Special Services Division 10/11-2 2013-Q1 $ - $ - ### $ 529,603 $ 211,841 $ (317,762)
69 Tulare LGA Tulare COE - Special Services Division 11/12-2 Err:520 $ 579,846 $ 231,938 $ 347,908 $ - ### $ - 2991
70 Tulare LGA Tulare COE - Special Services Division 10/11-3 2013-Q2 $ - $ - ### $ 484,170 $ 193,668 $ (290,502)
71 Tulare LGA Tulare COE - Special Services Division 11/12-3 Err:520 $ 612,710 $ 245,084 $ 367,626 $ - ### $ - 3788
72 Tulare LGA Tulare COE - Special Services Division 10/11-4 2013-Q3 $ - $ - ### $ 549,552 $ 219,821 $ (329,731)
73 Tulare LGA Tulare COE - Special Services Division 12/13-1 Err:520 $ 156,518 $ 62,607 $ 93,911 5331
74 Tulare LGA Tulare COE - Special Services Division 12/13-2 Err:520 $ 162,567 $ 65,027 $ 97,540 6132
75 Tulare LGA Tulare COE - Special Services Division 12/13-3 Err:520 $ 144,034 $ 57,614 $ 86,420 6898
76 Tulare LGA Tulare COE - Special Services Division 12/13-4 Err:520 $ 170,530 $ 68,212 $ 102,318
77 Madera Tulare COE - Special Services Division 13/14-1 Err:520 $ 145,763 $ 58,305 $ 87,458
78 Madera Tulare COE - Special Services Division 13/14-2 Err:520 $ 272,246 $ 108,898 $ 163,348
79 Madera Tulare COE - Special Services Division 13/14-3 Err:520 $ 194,700 $ 77,880 $ 116,820
80 Tulare LGA Tulare COE - Special Services Division 11/12-1C-1 Err:520 $ 538,194 $ 215,278 $ 322,916 $ - ### $ - 2196
81 Tulare LGA Tulare COE - Special Services Division 11/12-4C-1 Err:520 $ 218,519 $ 87,408 $ 131,111 $ - ### $ - 4562
82 Tulare COE - Special Services Division Total $ 3,195,627 $ 1,278,251 $ 1,917,376 $ 2,127,006 $ 850,802 $ (1,276,204) $ 2,047
83 Tulare LGA Tulare Joint Union HSD 11/12-1 Err:520 $ 32,932 $ 25,000 $ 7,932 $ - ### $ - 2 2197
84 Tulare LGA Tulare Joint Union HSD 10/11-2 2013-Q1 $ - $ - ### $ 32,407 $ 25,000 $ (7,407) 2
85 Tulare LGA Tulare Joint Union HSD 11/12-2 Err:520 $ 41,766 $ 31,325 $ 10,441 $ - ### $ - 2 2992
86 Tulare LGA Tulare Joint Union HSD 10/11-3 2013-Q2 $ - $ - ### $ 32,508 $ 25,000 $ (7,508) 2
87 Tulare LGA Tulare Joint Union HSD 11/12-3 Err:520 $ 33,228 $ 25,000 $ 8,228 $ - ### $ - 2 3789
88 Tulare LGA Tulare Joint Union HSD 10/11-4 2013-Q3 $ - $ - ### $ 31,545 $ 25,000 $ (6,545) 2
89 Tulare LGA Tulare Joint Union HSD 11/12-4C-1 Err:520 $ 34,640 $ 25,980 $ 8,660 $ - ### $ - 2 4564
90 Tulare Joint Union HSD Total $ 142,566 $ 107,305 $ 35,261 $ 96,460 $ 75,000 $ (21,460) $ 85,845
91 Tulare LGA Visalia USD 10/11-1 2012-Q4 $ - $ - ### $ 197,402 $ 197,402 $ -
A B C D E F G H I J K L M
Amount to be recouped
1 Period of Service Submitted for Payment Original Unpaid Settlement Amount for Unpaid Original Paid Deferred Settlement Amount from paid deferred Net (Column F + Option (insert 1 Placeholder
County Claiming Unit FY/QTR FFY/QTR Placeholder Amount Placeholders Due to LEC/LGA(75% & 40%) Amount to be released Amount for Paid Deferred claims Column J) or 2) Number
92 Tulare LGA Visalia USD 10/11-2 2013-Q1 $ - $ - ### $ 229,895 $ 229,895 $ -
93 Tulare LGA Visalia USD 10/11-3 2013-Q2 $ - $ - ### $ 242,963 $ 242,963 $ -
94 Tulare LGA Visalia USD 09/10-4 2012-Q3 $ - $ - ### $ 195,374 $ 195,374 $ -
95 Tulare LGA Visalia USD 10/11-4 2013-Q3 $ - $ - ### $ 227,761 $ 227,761 $ -
96 Tulare LGA Visalia USD 11/12-4 Err:520 $ - $ - $ - $ - ### $ -
97 Visalia USD Total $ - $ - $ - $ 1,093,395 $ 1,093,395 $ - $ -
98 Tulare LGA Woodlake Family Resource Center 10/11-2 2013-Q1 $ - $ - ### $ 33,821 $ 25,366 $ (8,455) 2
99 Tulare LGA Woodlake Family Resource Center 11/12-2 Err:520 $ 27,385 $ 25,000 $ 2,385 $ - ### $ - 2 2994
100 Tulare LGA Woodlake Family Resource Center 10/11-3 2013-Q2 $ - $ - ### $ 26,642 $ 25,000 $ (1,642) 2
101 Tulare LGA Woodlake Family Resource Center 11/12-3 Err:520 $ 28,387 $ 25,000 $ 3,387 $ - ### $ - 2 3791
102 Tulare LGA Woodlake Family Resource Center 10/11-4 2013-Q3 $ - $ - ### $ 39,965 $ 29,974 $ (9,991) 2
103 Woodlake Family Resource Center Total $ 55,772.00 $ 50,000.00 $ 5,772.00 $ 100,428 $ 80,340 $ (20,088) $ 29,912
104 Grand Total Tulare LGA $ 4,432,858 $ 2,101,892 $ 2,330,966 $ 4,721,458 $ 2,993,794 $ (1,727,664) $ 374,228
105
106
107 Column A County - Reporting LEC/LGA
108 Column B Claiming unit within county - Subtotals reflect offsetting between all paid and unpaid deferred invoices through Fiscal Years 10/11 and 11/12
109 Column C Period of Service in fiscal year and quarter format - Also referred to as the invoice number
110 Column D Submitted for Payment federal fiscal year and quarter - The federal fiscal year and quarter for when the invoice was submitted to be paid or early claimed
111 Column E The Original Unpaid Placeholder Amount is the original claim amount that was submitted to DHCS for payment
112 Column F The Settlement Amount agreed upon in the CMS letter dated October 7, 2014. For invoices >$25,000 & $50,000 a 75% payment will be made and for invoices >$50,000 a 40% payment will be made
113 Column G The unallowed amount for unpaid placeholders is the difference between the original invoice amount and the settlement amount
114 Column H The original paid deferred amount is the invoice amount that was paid according to the CMS 1-64 reports for quarters ending 12/31/11, 3/31/12, 6/30/12, 9/30/12
115 Column I The settlement amount for the paid deferred invoices represent the pay percentage according to the CMS letter dated October 7, 2014
116 Column J The remainder amount is the difference between the original paid deferred amount and the settlement amount for the deferred paid invoices. This is the amount due back to DHCS
117 Column K This is the subtotal column and represents the total amount owed to/from each claiming unit. It balances the unpaid deferred(what is owed to the CU) against the paid deferred(what is owed to DHCS)
118 The last subtotal amount is the final amount due to/from the LEC/LGA
119 Column L The option column is where the LEC/LGA will input which option they want their claiming unit to exercise for invoices that are >$25,000 & $50,000. Input a 1 or a 2, depending on which option chosen
120

121 Note1 If columns H,l,J are blank, this means the invoice is an unpaid, deferred placeholder
122 Note2 If columns E,F,G are blank, this means the invoice is a paid deferred placeholder
123 Note3 If columns E,F,G,H,l,J are all filled in, this is a subtotal row
124

125 Released Claiming Unit Invoice on placeholder to be paid 100%


126

127 Invoices on placeholder for amounts >$50,000 and a 40% payment will be made
128 Invoices on placeholder for amounts >$25,000 & $50,000 and a 75% payment will be made
129

130 Paid deferred invoices on the CMS I-64 Report for quarter ending 12/31/2011
131 Paid deferred invoices on the CMS I-64 Report for quarter ending 3/31/2012
132 Paid deferred invoices on the CMS I-64 Report for quarter ending 6/30/2012
133 Paid deferred invoices on the CMS I-64 Report for quarter ending 9/30/2012
134

135 Claiming units no longer participating (5% reduction)


136
137 12/13 claims
138 13/14 claims

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