4290 (Cont.),, FORM CMS-265-11 ,,,,,,06-13 BALANCE SHEET,,,, PROVIDER CCN:,, PERIOD:, WORKSHEET F, ,,,,,, From: ,, ,,,,,, To: ,, ,,,,,,,, ,ASSETS (omit cents),,,,,,, , CURRENT ASSETS,,Amount,,,,, 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 through 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 nondepreciable,,,25 ,,,, 26 , Other fixed assets,,,26 ,,,, 27 , TOTAL FIXED ASSETS (Sum of lines 12 through 26),,,27 ,,,, , OTHER ASSETS,,,,,,, 28 , Investments,,,28 ,,,, 29 , Deposits on leases,,,29 ,,,, 30 , Due from owners/officers,,,30 ,,,, 31 , Other assets,,,31 ,,,, 32 , TOTAL OTHER ASSETS (Sum of lines 28 through 31),,,32 ,,,, 33 ," TOTAL ASSETS (Sum of lines 11, 27, and 32)",,,33 ,,,, ,,,,,,,, ,LIABILITIES AND FUND BALANCES (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 current liabilities,,,41 ,,,, 42 , TOTAL CURRENT LIABILITIES (Sum of lines 34 through 41),,,42 ,,,, , LONG TERM LIABILITIES,,,,,,, 43 , Mortgage payable,,,43 ,,,, 44 , Notes payable,,,44 ,,,, 45 , Unsecured loans,,,45 ,,,, 46 , Other long term liabilities,,,46 ,,,, 47 ,,,,47 ,,,, 48 , TOTAL LONG TERM LIABILITIES (Sum of lines 43 through 47),,,48 ,,,, 49 , TOTAL LIABILITIES (Sum of lines 42 and 48),,,49 ,,,, , CAPITAL ACCOUNTS,,,,,,, 50 , FUND BALANCES,,,50 ,,,, 51 , TOTAL LIABILITIES AND FUND BALANCES (Sum of lines 49 and 50),,,51 ,,,, ,,,,,,,, ,( ) = contra amount,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, ,,,,,,,, "FORM CMS-265-11 (06/2013) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4216)",,,,,,,, ,,,,,,,, Rev. 2,,,,,,,,42-318