Worksheet G

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HERITAGE INN HEALTH AND REHABILITATI
STATESBORO, GA  30458

Medicare Provider Number: 115597
Cost report status: Settled Without Audit
[Record Code 422006 - 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:
115597
PERIOD:
FROM 07/01/2009
TO 06/30/2010
WORKSHEET G
Assets
(Omit cents)
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 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