RFP 712

State of Maryland Department of Human Resources Social SOCIAL SERVICES ADMINISTRATION Services Administration 311 W Revised Maintenance Payment Statement Saratoga Street Baltimore, MD 21201 Provider Name and Address Provider Phone: ( Extn): Payment ID: Statement Date: 4/14/11 Service Period : 3/1/2011 to 3/31/2011 Provider ID: Payment Summary Gross Amount: $485,241.49 Offset: $89,798.56 Net Amount: $395,442.93 Number of ChildrenGross Amount Provider Facility #1 5 $79,299.55 Provider Facility #2 2 $10,476.96 Provider Facility #3 5 $77,764.72 Provider Facility #4 2 $17,025.06 Minor Child 1 $8,928.62 Provider Facility #5 4 $73,256.72 Provider Facility #6 4 $73,256.72 Provider Facility #7 3 $54,942.54 Provider Facility #8 5 $44,643.10 Provider Facility #9 2 $36,628.36 Minor Child 1 $9,019.14 Total 34 $485,241.49 PROVIDER CERTIFICATION: Unless Provider contacts the DHR Hotline at 1-877-DHR2PAY (1-877-347-2729) regarding the client/s whose information is incorrect or fo r whom services have been previously paid, the provider certifies that the information on th is statement is true and correct.