Worksheet G
- Return to Cost Report Summary
- Form G000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
THE JEFFERSON
ARLINGTON, VA 22203-
ARLINGTON, VA 22203-
Medicare Provider Number: 495269
Cost report status: Settled Without Audit
[Record Code 155301 - 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: 495269 |
PERIOD: FROM 01/01/2001 TO 12/31/2001 |
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 |