SNFData - 115592 - 05/2013

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

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COUNTRYSIDE HEALTH CENTER
BUCHANAN, GA 30113

Medicare Provider Number: 115592

Cost report status: Settled Without Audit

[Record Code 1080724 - 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: 115592	PERIOD: FROM 07/01/2012 TO 05/31/2013	WORKSHEET G
Assets		General Fund	Specific Purpose Fund	Endowment Fund	Plant Fund
Assets		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
Liabilities and Fund Balances		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

Worksheet G