Worksheet G

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HEALTH CENTER AT BLOOMINGDALE
BLOOMINGDALE, NJ  07403

Medicare Provider Number: 315348
Cost report status: Settled Without Audit
[Record Code 1116075 - 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: 315348
PERIOD:
FROM 01/01/2014
TO 06/17/2014
 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