Worksheet A-7
- Return to Cost Report Summary
- Form A700
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
HITZ MEMORIAL HOME
ALHAMBRA, IL 62001
ALHAMBRA, IL 62001
Medicare Provider Number: 145921
Cost report status: Settled Without Audit
[Record Code 1249674 - 2010]
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| ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES | Provider CCN: 145921 | PERIOD: FROM 07/01/2018 TO 06/30/2019 |
WORKSHEET A-7 | ||||||
| Description | Beginning Balances | Acquisitions | Disposals and Retirements | Ending Balance | Fully Depreciated Assets | ||||
| Purchases | Donation | Total | |||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | |||
| 1 | Land | ### | ### | 1 | |||||
| 2 | Land Improvements | 2 | |||||||
| 3 | Buildings and Fixtures | ### | ### | ### | 3 | ||||
| 4 | Building Improvements | ### | ### | ### | ### | ### | 4 | ||
| 5 | Fixed Equipment | 5 | |||||||
| 6 | Movable Equipment | ### | ### | ### | ### | ### | ### | 6 | |
| 7 | Subtotal (sum of lines 1-6) | ### | ### | ### | ### | ### | ### | 7 | |
| 8 | Reconciling Items | 8 | |||||||
| 9 | Total (line 7 minus line 8) | ### | ### | ### | ### | ### | ### | 9 | |
| FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4115) | |||||||||
| Rev. 1 | 41-319 | ||||||||