04-99,,,,FORM CMS-1984-99,,,3890 (Cont.) ,BALANCE SHEET,,,PROVIDER NO:,PERIOD:,, (If you are nonproprietary and do not maintain fund-type,,,,,FROM, WORKSHEET G, "accounting records, complete the ""General Fund"" column only)",,,,,TO, (Cont.), Liabilities and Fund,,,,Specific,,, Balances,,,General,Purpose,Endowment,Plant, (Omit cents),,,Fund,Fund,Fund,Fund, ,,,1,2,3,4, 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 current liabilities,,,,,,41 42 ,TOTAL CURRENT LIABILITIES,,,,,,42 ,(Sum of lines 34 - 41),,,,,, LONG TERM LIABILITIES,,,,,,, 43 ,Mortgage payable,,,,,,43 44 ,Notes payable,,,,,,44 45 ,Unsecured loans,,,,,,45 46 ,Loans from owners: ,a. Prior to 7/1/66,,,,,46 ,,b. On or after 7/1/66,,,,, 47 ,Other long term liabilities,,,,,,47 48 ,,,,,,,48 49 ,TOTAL LONG TERM LIABILITIES,,,,,,49 ,(Sum of lines 43 - 48),,,,,, 50 ,TOTAL LIABILITIES,,,,,,50 ,(Sum of lines 42 and 49),,,,,, CAPITAL ACCOUNTS,,,,,,, 51 ,General fund balance,,,,,,51 52 ,Specific purpose fund,,,,,,52 53 ,Donor created - endowment fund,,,,,,53 ,balance - restricted,,,,,, 54 ,Donor created - endowment fund,,,,,,54 ,balance - unrestricted,,,,,, 55 ,Governing body created - endowment,,,,,,55 ,fund balance,,,,,, 56 ,Plant fund balance - invested in plant,,,,,,56 57 ,Plant fund balance - reserve for plant,,,,,,57 ,"improvement, replacement and expansion",,,,,, 58 ,TOTAL FUND BALANCES,,,,,,58 ,(Sum of lines 51 thru 57),,,,,, 59 ,TOTAL LIABILITIES AND FUND,,,,,,59 ,BALANCES (Sum of lines 50 and 58),,,,,, ,( ) = contra amount,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, ,,,,,,, FORM CMS-1984-99 (4/99) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SECTION 3850),,,,,,, ,,,,,,, Rev. 1,,,,,,,38-121