Worksheet G
- Return to Cost Report Summary
- Form G000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
SHENANDOAH VALLEY WESTMINSTER CANTER
WINCHESTER, VA 22603
WINCHESTER, VA 22603
Medicare Provider Number: 495165
Cost report status: Settled Without Audit
[Record Code 1265561 - 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: 495165 | PERIOD: FROM 01/01/2019 TO 12/31/2019 |
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) DUE RELATED PARTIES | 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 |