3290 (Cont.),,,,,,FORM CMS 1728-94        ,,,,,08-99
,              BALANCE SHEET,,,,, PROVIDER NO.:,,  PERIOD:,,,
 (To be completed by all providers maintaining fund type,,,,,,,,From:  ___________,,WORKSHEET F,
 accounting records.  Nonproprietary providers not,,,,,, ___________,,To: ___________,,,
" maintaining fund type accounting records, should",,,,,,,,,,,
" complete the ""General Fund"" column only.)",,,,,,,,,,,
,,,,,,,      SPECIFIC,,,,
,,,   ASSETS,,,GENERAL,      PURPOSE,,ENDOWMENT,PLANT,
,,,(Omit Cents),,,FUND,         FUND,,FUND,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: Allowance for uncollectible notes,,,,,,,,,, 6
, and accounts receivable,,,,,(                        ),,,,,
 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 Depreciation,,,,,(                        ),,,,,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,,,,,,,,,,,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 BALANCE,,,,,,,,,
,,,(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 (Specify),,,,,,,,,,41
42, TOTAL CURRENT LIABILITIES (Sum of lines 34-41),,,,,,,,,,42
,,       LONG TERM LIABILITIES,,,,,,,,,
43, Mortgage payable,,,,,,,,,,43
44, Notes payable,,,,,,,,,,44
45, Unsecured Loans,,,,,,,,,,45
46, Loans from owners - prior to 7/1/66,,,,,,,,,,46
47,Loans from owners - on or after 7/1/66,,,,,,,,,,47
48,Other (Specify),,,,,,,,,,48
49, TOTAL LONG TERM LIABILITIES ,,,,,,,,,,49
, (Sum of lines 43-48),,,,,,,,,,
50, TOTAL LIABILITIES (Sum of lines 42 and 49),,,,,,,,,,50
,,       CAPITAL ACCOUNTS,,,,,,,,,
51, General fund balance,,,,,,,,,,51
52, Specific purpose fund balance,,,,,,,,,,52
53, Donor created--Endowment fund balance--restricted,,,,,,,,,,53
54, Donor created--Endowment fund balance--unrestricted,,,,,,,,,,54
55, Governing body created--Endowment fund balance,,,,,,,,,,55
56, Plant fund balance--Invested in plant,,,,,,,,,,56
57," Plant fund balance-- Reserve for plant improvement,",,,,,,,,,,57
, replacement and expansion,,,,,,,,,,
58, TOTAL FUND BALANCES (Sum of lines 51 thru 57),,,,,,,,,,58
59, TOTAL LIABILITIES AND FUND BALANCE (Sum ,,,,,,,,,,59
, of lines 50 and 58),,,,,,,,,,
,,,,,(             ) = contra amount,,,,,,
"FORM CMS-1728-94-F  (12-1994)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3218)",,,,,,,,,,,
,,,,,,,,,,,
32-324,,,,,,,,,,,Rev. 7