SNFData - 345441 - 09/2009

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

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ALEXANDRIA PLACE
GASTONIA, NC 28054

Medicare Provider Number: 345441

Cost report status: Settled Without Audit

[Record Code 398083 - 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: 345441	PERIOD: FROM 10/01/2008 TO 09/30/2009	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