Worksheet G

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JACKSONVILLE HEALTH & REHAB LLC
JACKSONVILLE, AL  36265

Medicare Provider Number: 015391
Cost report status: Settled Without Audit
[Record Code 1309372 - 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: 015391
PERIOD:
FROM 07/01/2020
TO 06/30/2021
 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