SNFData - 525306 - 12/2007

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Form G000
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1

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BEVERLY LIVING-THE DORCHESTER
STURGEON BAY, WI 54235

Medicare Provider Number: 525306

Cost report status: Settled Without Audit

[Record Code 336332 - 1996]

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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 NO: 525306	PERIOD: FROM 03/19/2007 TO 12/31/2007	WORKSHEET G
Assets (Omit cents)		General Fund	Specific Purpose Fund	Endowment Fund	Plant Fund
Assets (Omit cents)		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 nondepreciable					25
26	Other fixed assets	###				26
27	TOTAL FIXED ASSETS (Sum of lines 12 - 26)	###				27
OTHER ASSETS
28	Investments					28
29	Deposits on leases					29
30	Due from owners/officers					30
31	Other assets	###				31
32	TOTAL OTHER ASSETS (Sum of lines 28 - 31)	###				32
33	TOTAL ASSETS (Sum of lines 11, 27 and 32)	###				33
Liabilities and Fund Balances (Omit cents)
	CURRENT LIABILITIES
34	Accounts payable	###				34
35	Salaries, wages & fees payable	###				35
36	Payroll taxes payable	###				36
37	Notes & loans payable (Short term)					37
38	Deferred income	###				38
39	Accelerated payments					39
40	Due to other funds					40
41	Other current liabilities	###				41
	TOTAL CURRENT LIABILITIES
42	(Sum of lines 34 - 41)	###				42
	LONG TERM LIABILITIES
43	Mortgage payable					43
44	Notes payable					44
45	Unsecured loans					45
46.01	Loans from owners: a. Prior to 7/1/66					46.01
46.02	b. On or after 7/1/66					46.02
47	Other long term liabilities	###				47
48						48
49	TOTAL LONG TERM LIABILITIES (Sum of lines 43 - 48)	###				49
50	TOTAL LIABILITIES (Sum of lines 42 and 49)	###				50
CAPITAL ACCOUNTS
51	General fund balance	###				51
52	Specific purpose fund					52
53	Donor created - endowment fund balance - restricted					53
54	Donor created - endowment fund balance - unrestricted					54
55	Governing body created - endowment fund balance expansion					55
56	Plant fund balance - invested in plant					56
57	Plant fund balance - reserve for plant improvement, replacement and expansion					57
58	TOTAL FUND BALANCES (Sum of lines 51 thru 57)	###				58
59	TOTAL LIABILITIES AND FUND BALANCES (Sum of lines 50 and 58)	###				59
60						60
	( ) = contra amount

Worksheet G