Name of Service: ___________________________________________

Type of Service: (  )Private   (  )Governmental   (   )City   (   )County
                             (  )Other: ____________________________________

For the most recent fiscal year:

Total Expenses: $_______________

Total Third-Party Revenue*: $_______________

*Third-Party Revenue should include payments from insurance companies, Medi-Care, Medicaid, patients, etc. Do not include subsidy payments from other entities such as cities, counties, hospitals, etc.

If you do not know this information please give the total subsidy you receive:
$_______________

This information will be collected and presented as a total dollar figure. Your organization will not be identified.

Please return before the end of Monday, Dec. 13 to John Blumenstock by phone (502-479-9103), fax (502-479-9150) or E-Mail (blu2work@aol.com)