Total
Employee Total

GT Independence

Budget Calculator

Trillium, 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 Trillium to fund or authorize services.



Consumer Information


Consumer Name:

Weeks in Auth:

Total Hours (based on 40 hour work week):

BeginsEnds
Authorization Period:
Authorization Number:
Agency:


Authorized Services


Select authorized service code and enter authorized hours

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


Employee Information


Enter Employee information

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

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
Accrual
HoursRateTotal
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
Total
*-These items are not subject to Payroll TaxTotal Authorized Dollars
Total Budgeted Dollars
Total Remaining for Future Use

HoursTotal
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

Notes


(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: