Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

08-05			FORM CMS 287-05			3990 (Cont.)
	BALANCE SHEET FOR HOME OFFICE	Home Office:		Period:	SCHEDULE J
				From:	page 1 of 5
				To:
					Balance
	Assets				Sheet
	(Omit Cents)				Per Books
	Current Assets				1
1	Cash - On Hand & In Bank					1
2	Current Investments					2
3	Notes Receivable					3
4	Accounts Receivable					4
5	Other Receivables (Specify)					5
6	Less:Allowance for Uncollectable Notes and Account Receivable					6
7	Inventory					7
8	Prepaid Expenses					8
9	Other Current Assets (Specify)					9
10	Total Current Assets (Sum of lines 1-9)					10
FORM CMS 287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
Rev. 1						39-131
3990 (Cont.)			FORM CMS 287-05			08-05
	BALANCE SHEET FOR HOME OFFICE				SCHEDULE J
					page 2 of 5
					Balance
	Assets				Sheet
	(Omit Cents)				Per Books
	Fixed Assets				1
11	Land					11
12	Land Improvements					12
13	Less: Accumulated Depreciation					13
14	Building					14
15	Less: Accumulated Depreciation					15
16	Leasehold Improvement					16
17	Less: Accumulated Depreciation					17
18	Fixed Equipment					18
19	Less: Accumulated Depreciation					19
20	Motor Vehicles					20
21	Less: Accumulated Depreciation					21
22	Major Movable Equipment					22
23	Less: Accumulated Depreciation					23
24	Minor Equipment - Depreciable					24
25	Less: Accumulated Depreciation					25
26	Minor Equipment - Non-Depreciable					26
27	Other Fixed Assets (Specify)					27
28	Other Fixed Assets (Specify)					28
29	Total Fixed Assets (Sum of lines 11-28)					29
FORM CMS 287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
39-132						Rev. 1
08-05			FORM CMS 287-05			3990 (Cont.)
	BALANCE SHEET FOR HOME OFFICE				SCHEDULE J
					page 3 of 5
					Balance
	Assets				Sheet
	(Omit Cents)				Per Books
	Other Assets				1
30	Investments					30
31	Deposits on Leases					31
32	Due from Owners/Officers					32
33	Due from Related Organizations					33
34	Special Funds					34
35	Goodwill					35
36	Construction in Progress					36
37	Other (Specify)					37
38	Total Other Assets (Sum of lines 30-37)					38
39	Total Assets (Sum of lines 10, 29, and 38)					39
FORM CMS 287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
Rev. 1						39-133
3990 (Cont.)			FORM CMS 287-92			08-05
	BALANCE SHEET FOR HOME OFFICE				SCHEDULE J
					page 4 of 5
					Balance
	Liabilities and Capital				Sheet
	(Omit Cents)				Per Books
	Liabilities				1
	Current Liabilities:
40	Accounts Payable					40
41	Notes and Loans Payable - Short Term					41
42	Current Portion of Long-Term Debt					42
43	Salaries, Wages and Fees Payable					43
44	Payroll Taxes Payable					44
45	Other Accrued Expenses Payable					45
46	Deferred Income					46
47	Notes and Loans Payable to Related Organization					47
48	Other (Specify)					48
49	Total Current Liabilities (Sum of lines 40-48)					49
	Long Term Liabilities:
50	Mortgage Payable (Long-term Portion)					50
51	Notes Payable - (Long-term Portion)					51
52	Unsecured Loans - (Long-term Portion)					52
53	Loans from Owners					53
54	Other (Specify)					54
55	Total Long-term Liabilities (Sum of lines 50-54)					55
56	Total Liabilities (Sum of lines 49 and 55)					56
FORM CMS 287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
39-134						Rev. 1
08-05			FORM CMS 287-05			3990 (Cont.)
	BALANCE SHEET FOR HOME OFFICE	Home Office:		Period:	SCHEDULE J
				From: ______________	page 5 of 5
				To: ________________
					Balance
	Liabilities and Capital				Sheet
	(Omit Cents)				Per Books
	Capital				1
57	Preferred Stock					57
58	Common Stock					58
59	Additional Paid-In Capital					59
60	Retained Earnings - Unrestricted					60
61	Other (Specify)					61
62	Total Capital (Sum of lines 57-61)					62
63	Total Liabilities and Total Capital (Sum of lines 56 and 62)					63
64	Equity in Assets Leased from Related Organizations (Attach supporting Schedules)					64
65	Equity in Related Organizations (attach Supporting Schedules)					65
66	Total Equity Capital (Lines 62 plus/minus 64 and 65)					66
FORM CMS 287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3919)
Rev. 1						39-135