US · guidance

CMS Pub. 100-06, ch. 5, § 510.9

Input Sheet for Cash Activity Items - This attachment is an illustration of the electronic

activein force · 2026-08-25 – presentas-observed

spreadsheet (Exhibit 1) that will be used to input selected financial information that is not available from

MCS system reports.

(Rev. 21, 08-01-03)

Section 510.9: Input Sheet for Cash Activity Items

Col. A Col. B Col. C Col. D Col. E Col. F Col. G

Journal Entry

LINE DATE Voids Stale Checks Stop Pays Refunds/Deposits Adjustments Do Not Forward

204 12/1/2002 0.00 0.00 0.00 0.00 0.00

205 12/2/2002 0.00 14,703.51 0.00 210,449.81 0.00

206 12/3/2002 411,354.19 0.00 67,887.51 122,233.34 0.00

207 12/4/2002 486,321.97 0.00 54.98 70,959.51 0.00

208 12/5/2002 1,634,262.78 0.00 243.45 169,532.86 0.00

209 12/6/2002 987,998.85 0.00 9,652.67 67,502.88 0.00

210 12/7/2002 0.00 0.00 0.00 0.00 0.00

211 12/8/2002 0.00 0.00 0.00 0.00 0.00

212 12/9/2002 154,369.09 0.00 9,346.12 206,965.75 0.00

213 12/10/2002 263,936.94 0.00 25,719.05 79,635.48 0.00

214 12/11/2002 408,658.22 0.00 12,780.47 96,806.14 0.00

215 12/12/2002 91,313.72 0.00 25,012.61 58,085.88 0.00

216 12/13/2002 420,237.34 0.00 5,594.63 133,095.66 0.00

217 12/14/2002 0.00 0.00 0.00 0.00 0.00

218 12/15/2002 0.00 0.00 0.00 0.00 0.00

219 12/16/2002 126,330.56 0.00 25,884.59 99,784.51 0.00

220 12/17/2002 200,225.96 0.00 2,460.61 93,383.17 0.00

221 12/18/2002 322,815.37 0.00 114,260.96 51,931.80 0.00

222 12/19/2002 173,552.81 0.00 5,989.32 116,754.07 0.00

223 12/20/2002 144,426.08 0.00 78,315.05 134,309.62 0.00

224 12/21/2002 0.00 0.00 0.00 0.00 0.00

225 12/22/2002 0.00 0.00 0.00 0.00 0.00

226 12/23/2002 372,536.52 0.00 0.00 396,332.04 0.00

227 12/24/2002 0.00 0.00 0.00 0.00 0.00

228 12/25/2002 0.00 0.00 0.00 0.00 0.00

229 12/26/2002 136,346.03 0.00 4,980.70 128,880.21 0.00

230 12/27/2002 278,585.61 0.00 41.10 128,987.55 0.00

231 12/28/2002 0.00 0.00 0.00 0.00 0.00

232 12/29/2002 0.00 0.00 0.00 0.00 0.00

233 12/30/2002 133,114.31 0.00 0.00 93,635.05 0.00

234 12/31/2002 0.00 0.00 0.00 0.00 0.00

235

236 Totals (55,088.48) 0.00 0.00 112,947.78 0.00 0.00

History

(Rev. 21, 08-01-03)

Provenance

Source: cms.gov
Retrieved: 2026-08-25
Edition: iom-2026-08-25
Content hash: cf3d424e24a3d3e3f4cc3f4150d23e10b19a002ef8db78c4e88b681de689c4fe

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