Worksheet G
- Return to Cost Report Summary
- Form G000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
Medicare Provider Number: -E
[Record Code 1322370 - 2010]
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BALANCE SHEET (If you are nonproprietary and do not maintain fund-type accounting records, complete the "General Fund" column only.) |
Provider CCN: | PERIOD: FROM 12/31/1969 TO 12/31/1969 |
WORKSHEET G | |||
| Assets | General Fund | Specific Purpose Fund | Endowment Fund | Plant Fund | ||
| 1 | 2 | 3 | 4 | |||
| CURRENT ASSETS | ||||||
| 1 | Cash on hand and in banks | 1 | ||||
| 2 | Temporary investments | 2 | ||||
| 3 | Notes receivable | 3 | ||||
| 4 | Accounts receivable | 4 | ||||
| 5 | Other receivables | 5 | ||||
| 6 | Less: allowances for uncollectible notes and accounts receivable | () | () | () | () | 6 |
| 7 | Inventory | 7 | ||||
| 8 | Prepaid expenses | 8 | ||||
| 9 | Other current assets | 9 | ||||
| 10 | Due from other funds | 10 | ||||
| 11 | TOTAL CURRENT ASSETS (sum of lines 1 - 10) | 11 | ||||
| FIXED ASSETS | ||||||
| 12 | Land | 12 | ||||
| 13 | Land improvements | 13 | ||||
| 14 | Less: Accumulated depreciation | () | () | () | () | 14 |
| 15 | Buildings | 15 | ||||
| 16 | Less Accumulated depreciation | () | () | () | () | 16 |
| 17 | Leasehold improvements | 17 | ||||
| 18 | Less: Accumulated Amortization | () | () | () | () | 18 |
| 19 | Fixed equipment | 19 | ||||
| 20 | Less: Accumulated depreciation | () | () | () | () | 20 |
| 21 | Automobiles and trucks | 21 | ||||
| 22 | Less: Accumulated depreciation | () | () | () | () | 22 |
| 23 | Major movable equipment | 23 | ||||
| 24 | Less: Accumulated depreciation | () | () | () | () | 24 |
| 25 | Minor equipment - Depreciable | 25 | ||||
| 26 | Minor equipment nondepreciable | 26 | ||||
| 27 | Other fixed assets | 27 | ||||
| 28 | TOTAL FIXED ASSETS (sum of lines 12 - 27) | 28 | ||||
| OTHER ASSETS | ||||||
| 29 | Investments | 29 | ||||
| 30 | Deposits on leases | 30 | ||||
| 31 | Due from owners/officers | 31 | ||||
| 32 | Other assets | 32 | ||||
| 33 | TOTAL OTHER ASSETS (sum of lines 29 - 32) | 33 | ||||
| 34 | TOTAL ASSETS (sum of lines 11, 28 and 33) | 34 | ||||
| Liabilities and Fund Balances | General Fund | Specific Purpose Fund | Endowment Fund | Plant Fund | ||
| 1 | 2 | 3 | 4 | |||
| CURRENT LIABILITIES | ||||||
| 35 | Accounts payable | 35 | ||||
| 36 | Salaries, wages & fees payable | 36 | ||||
| 37 | Payroll taxes payable | 37 | ||||
| 38 | Notes & loans payable (short term) | 38 | ||||
| 39 | Deferred income | 39 | ||||
| 40 | Accelerated payments | 40 | ||||
| 41 | Due to other funds | 41 | ||||
| 42 | Other current liabilities | 42 | ||||
| 43 | TOTAL CURRENT LIABILITIES (sum of lines 35 - 42) | 43 | ||||
| LONG TERM LIABILITIES | ||||||
| 44 | Mortgage payable | 44 | ||||
| 45 | Notes payable | 45 | ||||
| 46 | Unsecured loans | 46 | ||||
| 47 | Loans from owners: | 47 | ||||
| 48 | Other long term liabilities | 48 | ||||
| 49 | Other (specify) | 49 | ||||
| 50 | TOTAL LONG TERM LIABILITIES (sum of lines 44 - 49) | 50 | ||||
| 51 | TOTAL LIABILITIES (sum of lines 43 and 50) | 51 | ||||
| CAPITAL ACCOUNTS | ||||||
| 52 | General fund balance | 52 | ||||
| 53 | Specific purpose fund | 53 | ||||
| 54 | Donor created - endowment fund balance - restricted | 54 | ||||
| 55 | Donor created - endowment fund balance - unrestricted | 55 | ||||
| 56 | Governing body created - endowment fund balance | 56 | ||||
| 57 | Plant fund balance - invested in plant | 57 | ||||
| 58 | Plant fund balance - reserve for plant improvement, replacement and expansion | 58 | ||||
| 59 | TOTAL FUND BALANCES (sum of lines 52 thru 58) | 59 | ||||
| 60 | TOTAL LIABILITIES AND FUND BALANCES (sum of lines 51 and 59) | 60 | ||||
| ( ) = contra amount | ||||||
| FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140) | ||||||
| 05-11 | Rev. 1 | |||||