Employee Total

GT Independence

Budget Calculator

Sandhills, Employer of Record (EOR) Program

* This tool is for estimation of an individual budget and does not constitute an obligation on the part of GT Independence or Sandhills to fund or authorize services.

Consumer Information

Consumer Name:

Weeks in Auth:

Total Hours (based on 40 hour work week):

Authorization Period:
Authorization Number:

Authorized Services

Select authorized service code and enter authorized hours

Service CodeDescriptionUnitEffective DateEnd DateUnit RateHourly RateEffective Unit RateTotal Hours AuthorizedTotal Hours AllocatedBudget AuthorizedBudget Allocated

*Please ensure that the rate you have entered for any enhanced rates have been approved and authorized.

Employee Information

Enter Employee information

First NameLast NameService CodeHours Per WeekHours for Auth PeriodAnnual BonusEmployee BenefitsPay Rate (Per Hour)Gross Wages

Exempt Status
First NameLast NameNeeds TrainingFICAFUTASUTAFed Income TaxState Income Tax

Training Hours

First NameLast NameHours AllowedRateTotal
Training Total

Vacation Time Calculator

First NameLast NameVacation Hours Earned Per WeekRateTotal
Vacation Total

Mileage Calculator

First NameLast NameMileage Per WeekTotal
Mileage Total

Mandatory Taxes For Authorization Period

Social Security & Medicare
SUTA(State Unemployement)
FUTA(Federal Unemployement)
Worker's Compensation

Worker's Compensation

*Full Time for workers compensation is classified as 20 or more hours

# Full Time Workers# Part Time WorkersWorker's Compensation Total

Additional Benefits

Dollar Amount
Training (CPR, First Aid, and Bloodborne Pathogens)
Supplies/Misc. Costs
Supervisory Hours (Taxed)
Wage Premiums (overtime, emergency back-up staffing)

GT Independence

North Carolina Budget Calculator

Client Summary

Consumer Information

Authorized Start Date:

Authorized End Date:

Budget Summary

Direct CostsUnitsRateDollars
Indirect Costs
*-These items are not subject to Payroll TaxTotal Authorized Dollars
Total Budgeted Dollars
Total Remaining for Future Use

Self Directed Service Hours and Total Dollar Amount
Supervisory/Training Hours
Optional Benefit Hours, ex. Vacation, Sick
Total Base Salary Hours

The following expenses are proportionally allocated to the Cost Categories Above:

Payroll Taxes
Employee Benefits
Wage Premiums

Section B: Self-Directed Authorization Calculator

Employee NameHoursTotal

Payroll Taxes (2)
Worker's Compensation (3)
Employee Benefits
Retention Bonus (Included in Gross)
Vacation (Optional)
Mileage Reimbursement (Optional)
Emergency/Back-up Staffing Hours
Startup Training/Supervision Costs
Supplies/Misc Costs
Administrative Costs
Other Costs (Include Invoiced Services)
Reserved for other service related costs:
Total Budget


(1)These hours are added for supervisory/training time spent with staff.
Employees would be paid for the time supervised/trained, but the hours would not be billed to Medicaid.
(2)Breakdown of Benefits %
Social Security and Medicare 7.65%
SUTA (State Unemployement Tax Act) 1.20%
FUTA (Federal Unemployement Tax Act)1.80%
(3)Worker's Compensation is based on the rate set

* This tool is for estimation of an individual budget and does not constitute an obligation on the part of GT Independence or Alliance to fund or authorize services.

I Understand and Agree to the Following:

EOR Signature: ________________________________________________________ Date: ___________________

Community Navigator Signature: ________________________________________________________ Date: ___________________

Save info: