<p> Arkansas Division of Medical Services DDTCS Transportation Survey</p><p>DDTCS Transportation Provider Name______Medicaid DDTCS Transportation Provider Number______Fiscal Reporting Period______through______(Information not required if less than 6 months)</p><p>Total DDTCS Passenger Miles______Total DDTCS Non-Passenger Miles______Total DDTCS Miles______</p><p>Unduplicated Count of Medicaid DDTCS Clients Transported______Unduplicated Count of NonMedicaid DDTCS Clients Transported______</p><p>Medicaid DDTCS Transportation Revenue______NonMedicaid DDTCS Transportation Revenue______Total DDTCS Transportation Revenue______</p><p>Direct Costs – DDTCS Transportation Drivers Salaries $______Drivers Fringes/Payroll Taxes $______Escorts Salaries $______Escorts Fringes/Payroll Taxes $______Other Salaries $______Other Fringes/Payroll Taxes $______Program Supplies $______Vehicle Repairs/Maint. $______Gas and Oil $______Vehicle Rent $______Vehicle Insurance $______Vehicle Depreciation $______Vehicle Interest $______Training $______Direct Utilities $______Direct Telephone $______Direct Building Rent $______Direct Building Utilities $______Direct Building Depreciation $______Direct Building Interest $______Other - ______$______Other - ______$______Other - ______$______</p><p>Total Direct Costs – DDTCS Transportation $______</p><p>Indirect/Overhead Costs – DDTCS Transportation $______</p><p>Total DDTCS Transportation Costs $______</p><p>(Report Cost in Dollars Only, No Cents)</p><p>DMS-632 (7-1-00)</p>