Worksheet G
- Return to Cost Report Summary
- Form G000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
DUNN NURSING HOME INC.
SELMA, AL 36701-
SELMA, AL 36701-
Medicare Provider Number: 015084
Cost report status: Settled Without Audit
[Record Code 198761 - 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: 015084 |
PERIOD: FROM 07/01/2002 TO 06/30/2003 |
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 | ||||||