UNYEIP Survey On Billed Vs. Received April - June 2013 Question Title * 1. Indicate your present position in NYS Early Intervention. Independent Contractor Subcontractor Agency Employee Municipality Employee Small Agency Owner Large Agency Owner Large Agency Director Question Title * 2. Indicate the municipalities that you presently provide Early Intervention Services in. Albany Allegany Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Lewis Livingston Madison Monroe Montgomery Nassau Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Rensselaer Rockland Saratoga Schenectady Schoharie Schuyler Seneca St Lawrence Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates Bronx Brooklyn Manhattan Queens Staten Island Question Title * 3. Please review your April Billing submitted. In the space provided, please indicated the dollar amount billed vs. the dollar amount received. Be exacting. Do NOT indicate the specific source of payments received, just the dollar amount received. April Dollar Amount Billed: April Dollar Amount Received: Question Title * 4. Please review your May Billing submitted. In the space provided, please indicated the dollar amount billed vs. the dollar amount received. Be exacting. Do NOT indicate the specific source of payments received, just the dollar amount received. May Dollar Amount Billed: May Amount Received: Question Title * 5. Please review your June Billing submitted. In the space provided, please indicated the dollar amount billed vs. the dollar amount received. Be exacting. Do NOT indicate the specific source of payments received, just the dollar amount received. June Dollar Amount Billed: June Dollar Amount Received: Question Title * 6. Please reflect on the remuneration received from April 1st to date. Significant Improvement Noted Moderate Improvement Noted Insignificant Improvement Noted No Improvement Noted Comment on remuneration received. Question Title * 7. If you have not received adequate payments to satisfy your financial obligations, please indicate which obligations at present that you are unable to meet. Mortgage NYS Property Taxes Utilities Child Care Federal Personal Student Loan Child's College Tuition Payment Cell Phone Internet/Cable Health Insurance Premium Non-Covered Medical Prescriptions Business Credit Line Loan Life Insurance Premium Car Loan Car Insurance Child Support --Court Mandated/Voluntary Alimony -- Court Mandated/Voluntary Miscellaneous State Quarterly Taxes Miscellaneous Federal Quarterly Taxes NYS Department of Labor Quarterly Payments Car Repair Home Repair Equity Loan Payment Dental Bill Credit Card Payments List Other Significant Financial Obligations Question Title * 8. Have delinquencies noted in Question 4 resulted in collection action? If yes, please describe. Yes No Other (please specify) Question Title * 9. If you are operating an agency, have insufficient payments received resulted in an inability to pay your providers? Yes No If yes, describes the steps you have taken to thwart this result. Done