(1) Liability (Premises and Operations): Total monthly cost of liability insurance covering the premises
(2) Liability (Vehicles): Total monthly cost of liability insurance covering all of the vehicles used in
support of the family day home operation.
(3) Other: Total monthly cost of other types of insurance (e.g. fire insurance). NOTE: Health Care,
Group Life, and other insurance benefiting employees should be shown under Item 3.a. Salaries, Wages
& Benefits and not in this item.
f. Advertising: Total monthly cost to advertise the family day home.
3. SALARIES, WAGES & BENEFITS PER MONTH:
a. Salaries & Wages: All salaries and wages paid per month by the family day home to its employees.
b. FICA (Social Security): Enter the total monthly FICA (Social Security) tax, (including both OASDI and
Medicare) to be paid by the facility for all employees and listed above.
c. Health Insurance: Total amount of monthly premiums paid by the family day home for health care
insurance for employees listed above when the cost of all or part of such insurance is provided by the
family day home. Do not include portions paid by employees.
d. Life Insurance: Total amount of monthly premiums paid by the family day home for employee life
insurance when the cost of all or part of such insurance is provided by the family day home.
e. Employee Training: Total monthly cost for formal training for employees that will be paid for or
reimbursed by the family day home.
f. Other Benefits (Specify): On an item-by-item basis, the cost(s) of any additional benefits provided by the
family day home to employees listed above.
Employee Taxes: Taxes which must be paid by the family day home. This would include VEC taxes and Federal
Unemployment Taxes which must be paid on employees' salaries. NOTE: The Employer's FICA (Social
Security) taxes must be shown under Item 3, b above and not in this item. Specify each tax on a separate line
under the entry “taxes.”
Other (Specify): Monthly cost of all other expenses not included in other items. Specify each item of expense
included here and the expense amount (e.g. the estimated cost of meals provided at no cost to employees would be