SNFData - 365324 - 05/2016

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

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MC-BELDEN VILLAGE OF CANTON OH LLC
CANTON, OH 44718

Medicare Provider Number: 365324

Cost report status: Settled Without Audit

[Record Code 1177606 - 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: 365324	PERIOD: FROM 06/01/2015 TO 05/31/2016	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