Form CMS-287-21 Home Office Cost Statement

Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)

R1P248f.xlsx

Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)

OMB: 0938-0202

Document [xlsx]
Download: xlsx | pdf

Overview

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Sheet 1: S

MM-YY
















FORM CMS-287-21
















4895





FORM APPROVED




OMB NO. 0938-0202




EXPIRES MM/DD/YYYY
HOME OFFICE COST STATEMENT CERTIFICATION




















HOME OFFICE



PERIOD:



SCHEDULE S


























NUMBER:




FROM:

____________



























_________________
TO: ____________








































































PART I - COST STATEMENT STATUS - CONTRACTOR USE ONLY




































1 Amended cost statement

































1
2 Amendment number

































2
3 Cost statement received date

































3
4 First cost statement for this home office number

































4
5 Last cost statement for this home office number

































5
6 Cost statement status

































6
7 Reopening number

































7
8 NPR date

































8
9 Contractor number

































9
10 ECR software vendor code

































10






































PART II - CERTIFICATION




















































































































SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR









CHECKBOX






ELECTRONIC SIGNATURE STATEMENT

















1









2



1





















1











































































2 Signatory Printed Name

































2
3 Signatory Title

































3
4 Signature date

































4































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4801 THROUGH 4801.12.)




































Rev. 1


































48-503

Sheet 2: S-1

4895



















FORM CMS-287-21



















MM-YY
IDENTIFICATION DATA

































HOME OFFICE



PERIOD:



SCHEDULE S-1






































NUMBER:




FROM:

____________







































_________________
TO: ____________































































































PART I - HOME OFFICE DATA





























































STREET ADDRESS LINE 1









STREET ADDRESS LINE 2




P O BOX



CITY




STATE

ZIP














1









2




3



4




5

6

1 Home Office Location














































1














































































HOME OFFICE

DATE OPERATIONS

REPORTING PERIOD








HOME OFFICE NAME NUMBER

BEGAN



BEGINNING DATE



ENDING DATE










1 2

3



4



5


2 Home Office Information














































2





























































TYPE OF CONTROL








DESCRIPTION






































1








2



























3 Home Office Control














































3
































































RECONCILE TO




















PREPARED BY CPA A / C / R SUBMITTED DATE AVAILABLE

COST STATEMENT




















1 2 3 4

5












4 Financial Statements














































4





























































FIRST NAME





LAST NAME


TITLE TELEPHONE NUMBER EMAIL ADDRESS

EMPLOYER













1





2


3 4 5

6


5 Contact Information














































5


















































PART II - KEY OFFICERS DATA




















































POSITION / JOB TITLE












EMPLOYEE NAME


































1












2






























1 President














































1
2 Vice President














































2
3 Secretary














































3
4 Treasurer














































4
5 Controller














































5
6















































6
7















































7
8















































8
9















































9
10















































10
11















































11
12















































12
13















































13
14















































14
15















































15
16















































16
17















































17
18















































18
19















































19
20















































20






















































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4801.20 THROUGH SECTION 4801.22.)
















































48-504















































Rev. 1

Sheet 3: S-2

MM-YY



















FORM CMS-287-21



















4895
LISTING OF COMPONENTS

































HOME OFFICE



PERIOD:



SCHEDULE S-2






































NUMBER:




FROM:

____________







































_________________
TO: ____________































































































PART I - HEALTHCARE PROVIDER COMPONENTS






























































REPORTING PERIOD ENDING
DATE SOLD / MEDICAID REIMBURSE-














OWNED OR
DURING HO FISCAL YEAR DATE CEASED PARTICI- MENT MEDICARE MEDICAID





COMPONENT NAME



CCN
MANAGED
BEGINNING ENDING ACQUIRED PARTICIPATION PATION TYPE CONTRACTOR CONTRACTOR





1



2
3
4 5 6 7 8 9 10 11
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50


















































PART II - NON-HEALTHCARE COMPONENTS






























































REPORTING PERIOD ENDING
DATE MEDICAID REIMBURSE-
















DURING HO FISCAL YEAR DATE SOLD / PARTICI- MENT MEDICARE MEDICAID





COMPONENT NAME







BEGINNING ENDING ACQUIRED CLOSED PATION TYPE CONTRACTOR CONTRACTOR





1



2
3
4 5 6 7 8 9 10 11
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50


















































PART III - REGION / DIVISION COMPONENTS


















































































COSTS SEPARATE



































INCLUDED COST REGION /










REGIONAL


REGION / DIVISION LOCATION IN THIS COST STATEMENT DIVISION





COMPONENT NAME



HO NUMBER


CITY STATE STATEMENT FILED CONTRACTOR





1



2
3
4 5 6 7 8
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50






























































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4801.30 THROUGH SECTION 4801.33.)
















































Rev. 1















































48-505

Sheet 4: A

4895



















FORM CMS-287-21



















MM-YY
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

































HOME OFFICE



PERIOD:



SCHEDULE A






































NUMBER:




FROM:

____________







































_________________
TO: ____________
















































































































EXPENSES



DIRECT FUNCTIONAL


















PER
RECLASSIFIED
NET ALLOCATIONS ALLOCATIONS


















HOME OFFICE RECLASS- TRIAL
ALLOWABLE TO TO POOLED

















BOOKS IFICATIONS BALANCE ADJUSTMENTS EXPENSES COMPONENTS COMPONENTS ALLOCATIONS

















1 2 3 4 5 6 7 8


CAPITAL RELATED COST CENTERS














































1 CRC-B&F














































1
2 CRC-ME














































2
3 Subtotal














































3


OTHER CAPITAL RELATED COST CENTERS














































4 Insurance Premiums














































4
5 Taxes & Licenses














































5
6 Other Capital Related














































6
7 Subtotal














































7


NON-CAPITAL RELATED COSTS














































8 Salaries of Officers














































8
9 Salaries and Wages of Others














































9
10 Payroll Taxes














































10
11 Employee Benefits - Payroll Related














































11
12 Employee Benefits - Non-Payroll Related














































12
13 Profit Sharing/Pension Plans














































13
14 Legal Fees














































14
15 Auditing and Accounting Fees














































15
16 Utilities














































16
17 Communications














































17
18 Travel and Entertainment














































18
19 Transportation














































19
20 Cleaning, Office & Admin. Supplies














































20
21 Minor Equipment














































21
22 Repairs and Maintenance














































22
23 Dues and Subscriptions














































23
24 Contributions














































24
25 Insurance Premiums - Non-Cap. Related














































25
26 Taxes & Licenses - Non-Cap. Related














































26
27 Interest Expense














































27
28 Interest Income














































28
29















































29
30















































30


























































































































































































































































99 Subtotal














































99
100 Total














































100








































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802 THROUGH SECTION 4802.10.)
















































48-506















































Rev. 1

Sheet 5: A-6

MM-YY



















FORM CMS-287-21



















4895
RECLASSIFICATIONS OF EXPENSES

































HOME OFFICE



PERIOD:



SCHEDULE A-6






































NUMBER:




FROM:

____________







































_________________
TO: ____________






















































































































INCREASES DECREASES






















SCHEDULE A COST CENTER
SCHEDULE A COST CENTER











DESCRIPTION OF RECLASSIFICATION









CODE


DESCRIPTION



LINE #

AMOUNT



DESCRIPTION



LINE #

AMOUNT











1









2


3



4

5



6



7

8

1















































1
2















































2
3















































3
4















































4
5















































5
6















































6
7















































7
8















































8
9















































9
10















































10
11















































11
12















































12
13















































13
14















































14
15















































15
16















































16
17















































17
18















































18
19















































19
20















































20
21















































21
22















































22
23















































23
24















































24
25















































25
26















































26
27















































27
28















































28
29















































29
30















































30




















































































































































































































































































































































































































































































































100 Total reclassifications














































100








































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.70.)
















































Rev. 1















































48-507

Sheet 6: A-7

4895



















FORM CMS-287-21



















MM-YY
ANALYSIS OF CAPITAL COST CENTERS

































HOME OFFICE



PERIOD:



SCHEDULE A-7






































NUMBER:




FROM:

____________







































_________________
TO: ____________































































































PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES














































































RETIREMENTS
FULLY


















BEGINNING ACQUISITIONS AND ENDING DEPRECIATED


















BALANCE PURCHASES DONATIONS TOTAL DISPOSALS BALANCE ASSETS


















1 2 3 4 5 6 7

1 Land














































1
2 Land Improvements














































2
3 Buildings & Fixtures














































3
4 Building Improvements














































4
5 Fixed Equipment














































5
6 Movable Equipment














































6
7 Subtotal














































7
8 Reconciling Items














































8
9 Total














































9


















































PART II - RECONCILIATION OF CAPITAL COST CENTERS

































































COMPUTATION OF RATIOS ALLOCATION OF OTHER CAPITAL RELATED COSTS

















GROSS CAPITALIZED GROSS ASSETS
INSURANCE TAXES & OTHER


















ASSETS LEASES FOR RATIO RATIO PREMIUMS LICENSES CAPITAL REL TOTAL

















1 2 3 4 5 6 7 8
1 CRC-B&F














































1
2 CRC-ME














































2
3 Total














































3

























































































































SUMMARY OF CAPITAL





















DEPRE-

INSURANCE TAXES & OTHER






















CIATION LEASE INTEREST PREMIUMS LICENSES CAPITAL REL TOTAL





















9 10 11 12 13 14 15
1 CRC-B&F














































1
2 CRC-ME














































2
3 Total














































3


















































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4802.80 THROUGH SECTION 4802.82.)
















































48-508















































Rev. 1

Sheet 7: A-8

MM-YY



















FORM CMS-287-21



















4895
ADJUSTMENTS TO EXPENSES

































HOME OFFICE



PERIOD:



SCHEDULE A-8






































NUMBER:




FROM:

____________







































_________________
TO: ____________




































































































































SCHEDULE A COST CENTER












DESCRIPTION OF ADJUSTMENT
















BASIS


AMOUNT





DESCRIPTION




LINE #













1
















2


3





4




5

1 Federal, state income tax, franchise tax, and related interest and penalties on late payments (CMS Pub. 15-1, chapter 21, §2122.2)














































1
2 Stockholders servicing costs (CMS Pub. 15-1, chapter 21, §2134.9)














































2
3 Acquisition expenses (CMS Pub. 15-1, chapter 21, §2134.11)














































3
4 Bad debts (CMS Pub. 15-1, chapter 3, §308)














































4
5 Life insurance premiums where home office is direct/indirect beneficiary (CMS Pub. 15-1, chapter 21, §2130)














































5
6 Annual stockholder meeting expenses (CMS Pub. 15-1, chapter 21, §2134.9)














































6
7 Non-healthcare projects (CMS Pub. 15-1, chapter 21, §2102.3)














































7
8 Non-competition agreement expenses (CMS Pub. 15-1, chapter 21, §2105.1)














































8
9 Fund-raising expenses (CMS Pub. 15-1, chapter 21, §2136.2)














































9
10 Rebates/refunds on expenses (CMS Pub. 15-1, chapter 8, §804)














































10
11 Cost of ownership of assets leased from related organization in lieu of rent (CMS Pub. 15-1, chapter 10, §1011.5)














































11
12 Related organizations (CMS Pub. 15-1, chapter 10, §1000)



























Sch. A-8-1

















12
13 Value of services of non-paid workers (CMS Pub. 15-1, chapter 7, §700)














































13
14 Interest on loans between home office and components (CMS Pub. 15-1, chapter 21, §2150.2C)














































14
15 Costs of corporate acquisitions of capital stocks and acquisition & development department (CMS Pub. 15-1, chapter 21, §2150.2B)














































15
16 Interest on loans paid to owners/partners (CMS Pub. 15-1, chapter 2, §218)














































16
17 Abandoned construction in progress cost (CMS Pub. 15-1, chapter 21, §2155)














































17
18















































18
19















































19
20















































20
21















































21
22















































22
23















































23
24















































24
25















































25
26















































26
27















































27
28















































28
29















































29
30















































30




















































































































































































































































































































































































































































































































100 Total














































100


























































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.90.)
















































Rev. 1















































48-509

Sheet 8: A-8-1

4895



















FORM CMS-287-21



















MM-YY
COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND / OR HOME OFFICE / CHAIN ORGANIZATIONS

































HOME OFFICE



PERIOD:



SCHEDULE A-8-1






































NUMBER:




FROM:

____________







































_________________
TO: ____________































































































PART I - ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS AND / OR HOME OFFICE / CHAIN ORGANIZATIONS
















































































AMOUNT



AMOUNT








SCHEDULE A COST CENTER




















PART II


ALLOWABLE



INCLUDED IN



NET




LINE #



DESCRIPTION











EXPENSE ITEM DESCRIPTION










LINE #


IN COST



SCH. A, COL. 3



ADJUSTMENT




1



2











3










4


5



6



7


1















































1
2















































2
3















































3
4















































4
5















































5
6















































6
7















































7
8















































8
9















































9
10















































10


























































































































































































































































100 TOTAL














































100


















































PART II - INTERRELATIONSHIP OF HOME OFFICE / CHAIN ORGANIZATION TO RELATED ORGANIZATIONS

















































INTERRELA-








































TIONSHIP












PERCENTAGE












PERCENTAGE












SYMBOL





NAME OF RELATED INDIVIDUAL





OWNERSHIP





RELATED ORGANIZATION NAME





OWNERSHIP TYPE OF BUSINESS

1





2





3





4





5 6
1















































1
2















































2
3















































3
4















































4
5















































5
6















































6
7















































7
8















































8
9















































9
10















































10








































































































































































































50















































50






























































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.100 THROUGH SECTION 4802.102.)
















































48-510















































Rev. 1

Sheet 9: B Dir Cap

MM-YY



















FORM CMS-287-21



















4895
DIRECT ALLOCATION OF CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE B






































NUMBER:




FROM:

____________







































_________________
TO: ____________































































































PART I - HEALTHCARE PROVIDER COMPONENTS



































































CAPITAL RELATED






OTHER CAPITAL RELATED

































CRC-



CRC-



INSURANCE



TAXES &



OTHER




























B&F



ME



PREMIUMS



LICENSES



CAPITAL RELATED



TOTAL










COMPONENT NAME







CCN


1



2



4



5



6



7


1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































PART II - NON-HEALTHCARE COMPONENTS



































































CAPITAL RELATED






OTHER CAPITAL RELATED

































CRC-



CRC-



INSURANCE



TAXES &



OTHER




























B&F



ME



PREMIUMS



LICENSES



CAPITAL RELATED



TOTAL










COMPONENT NAME











1



2



4



5



6



7


1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































PART III - REGION / DIVISION COMPONENTS



































































CAPITAL RELATED






OTHER CAPITAL RELATED





























REGIONAL


CRC-



CRC-



INSURANCE



TAXES &



OTHER
























HO


B&F



ME



PREMIUMS



LICENSES



CAPITAL RELATED



TOTAL










COMPONENT NAME







NUMBER


1



2



4



5



6



7


1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52








































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803 THROUGH SECTION 4803.13.)
















































Rev. 1















































48-511

Sheet 10: B-1 Dir Non-Cap

4895



















FORM CMS-287-21



















MM-YY
DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE B-1,






































NUMBER:




FROM:

____________ PART I






































_________________
TO: ____________































































































PART I - HEALTHCARE PROVIDER COMPONENTS






























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL


















OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-















OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON






COMPONENT NAME




CCN

8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &






























OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST
























ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL






COMPONENT NAME




CCN

20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)
















































48-512















































Rev. 1
MM-YY



















FORM CMS-287-20



















4895
DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE B-1,






































NUMBER:




FROM:

____________ PART II






































_________________
TO: ____________































































































PART II - NON-HEALTHCARE COMPONENTS






























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL


















OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-















OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON






COMPONENT NAME







8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &






























OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST
























ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL






COMPONENT NAME







20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)
















































Rev. 1















































48-513
4895



















FORM CMS-287-20



















MM-YY
DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE B-1,






































NUMBER:




FROM:

____________ PART III






































_________________
TO: ____________































































































PART III - REGION / DIVISION COMPONENTS






























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL















REGIONAL

OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-












HO

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON






COMPONENT NAME




NUMBER

8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &



























REGIONAL

OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST





















HO

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL






COMPONENT NAME




NUMBER

20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52






















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)
















































48-514















































Rev. 1

Sheet 11: C Func Cap

MM-YY
















FORM CMS-287-21
















4895
FUNCTIONAL ALLOCATION OF CAPITAL RELATED COSTS




















HOME OFFICE



PERIOD:



SCHEDULE C

























NUMBER:




FROM:

____________


























_________________
TO: ____________





































































PART I - HEALTHCARE PROVIDER COMPONENTS































































































CRC-



CRC-






























B&F



ME



TOTAL










COMPONENT NAME









CCN


1



2



3


1


































1
2


































2
3


































3
4


































4
5


































5










































































50


































50
51 Total

































51





































PART II - NON-HEALTHCARE COMPONENTS































































































CRC-



CRC-






























B&F



ME



TOTAL










COMPONENT NAME













1



2



3


1


































1
2


































2
3


































3
4


































4
5


































5










































































50


































50
51 Total

































51





































PART III - REGION / DIVISION COMPONENTS


























































































REGIONAL


CRC-



CRC-


























HO


B&F



ME



TOTAL










COMPONENT NAME









NUMBER


1



2



3


1


































1
2


































2
3


































3
4


































4
5


































5










































































50


































50
51 Total

































51
52 Grand Total

































52



















































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4804 THROUGH 4804.13.)



































Rev. 1


































48-515

Sheet 12: C-1 FC Stats

4895
















FORM CMS-287-21
















MM-YY
FUNCTIONAL ALLOCATION OF CAPITAL RELATED COSTS - STATISTICS




















HOME OFFICE



PERIOD:



SCHEDULE C-1

























NUMBER:




FROM:

____________


























_________________
TO: ____________





































































PART I - HEALTHCARE PROVIDER COMPONENTS


























































CRC-



CRC-






























B&F



ME






























(ENTER



(ENTER






























BASIS)



BASIS)















COMPONENT NAME









CCN


1



2







1


































1
2


































2
3


































3
4


































4
5


































5










































































50


































50
51 Total

































51





































PART II - NON-HEALTHCARE COMPONENTS


























































CRC-



CRC-






























B&F



ME






























(ENTER



(ENTER






























BASIS)



BASIS)















COMPONENT NAME













1



2







1


































1
2


































2
3


































3
4


































4
5


































5










































































50


































50
51 Total

































51





































PART III - REGION / DIVISION COMPONENTS


























































CRC-



CRC-






























B&F



ME


























REGIONAL


(ENTER



(ENTER


























HO


BASIS)



BASIS)















COMPONENT NAME









NUMBER


1



2







1


































1
2


































2
3


































3
4


































4
5


































5










































































50


































50
51 Total

































51
52 Grand Total

































52
53 Cost to be allocated

































53
54 UCM

































54


























































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4804.20 THROUGH SECTION 4804.23.)



































48-516


































Rev. 1

Sheet 13: D Func Non-Cap

MM-YY



















FORM CMS-287-21



















4895
FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE D,






































NUMBER:




FROM:

____________ PART I






































_________________
TO: ____________































































































PART I - HEALTHCARE PROVIDER COMPONENTS






























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL


















OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-















OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON






COMPONENT NAME




CCN

8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &






























OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST
























ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL






COMPONENT NAME




CCN

20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)
















































Rev. 1















































48-517
4895



















FORM CMS-287-20



















MM-YY
FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE D,






































NUMBER:




FROM:

____________ PART II






































_________________
TO: ____________































































































PART II - NON-HEALTHCARE COMPONENTS






























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL


















OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-















OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON






COMPONENT NAME







8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &






























OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST
























ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL






COMPONENT NAME







20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


























































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)
















































48-518















































Rev. 1
MM-YY



















FORM CMS-287-20



















4895
FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE D,






































NUMBER:




FROM:

____________ PART III






































_________________
TO: ____________































































































PART III - REGIONAL OFFICE / DIVISION COMPONENTS PART III - REGION / DIVISION COMPONENTS





























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL















REGIONAL

OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-












HO

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON






COMPONENT NAME




NUMBER

8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &



























REGIONAL

OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST





















HO

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL






COMPONENT NAME




NUMBER

20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52






















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)
















































Rev. 1















































48-519

Sheet 14: D-1 FNC Stats

4895



















FORM CMS-287-21



















MM-YY
FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS - STATISTICS

































HOME OFFICE



PERIOD:



SCHEDULE D-1,






































NUMBER:




FROM:

____________ PART I






































_________________
TO: ____________































































































PART I - HEALTHCARE PROVIDER COMPONENTS






























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL


















OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-















OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON















(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER















BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)






COMPONENT NAME




CCN

8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &






























OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST
























ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL















(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER







(ENTER















BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)







BASIS)






COMPONENT NAME




CCN

20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)
















































48-520















































Rev. 1
MM-YY



















FORM CMS-287-20



















4895
FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS - STATISTICS

































HOME OFFICE



PERIOD:



SCHEDULE D-1,






































NUMBER:




FROM:

____________ PART II






































_________________
TO: ____________































































































PART II - NON-HEALTHCARE COMPONENTS






























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL


















OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-















OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON















(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER















BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)






COMPONENT NAME







8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &






























OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST
























ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL















(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER







(ENTER















BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)







BASIS)






COMPONENT NAME







20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)
















































Rev. 1















































48-521
4895



















FORM CMS-287-20



















MM-YY
FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS - STATISTICS

































HOME OFFICE



PERIOD:



SCHEDULE D-1,






































NUMBER:




FROM:

____________ PART III






































_________________
TO: ____________































































































PART III - REGION / DIVISION COMPONENTS






























































SALARIES

SALARIES




EMPLOYEE

EMPLOYEE

PROFIT




AUDIT /




COM-

TRAVEL


















OF

& WAGES

PAYROLL

BENEFITS

BENEFITS

SHARING/

LEGAL

ACCOUNT-




MUN-

AND

TRANS-















OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON












REGIONAL

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER












HO

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)






COMPONENT NAME




NUMBER

8

9

10

11

12

13

14

15

16

17

18

19

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52
53 Cost to be allocated














































53
54 UCM














































54
































































CLEANING,




REPAIRS

DUES

CON-

INSUR

TAXES &






























OFFICE,

MINOR

AND

AND

TRIBU-

PREM

LICENSES

INTEREST

INTEREST
























ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

NON-CAP

EXPENSE

INCOME







TOTAL












REGIONAL

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER

(ENTER







(ENTER












HO

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)

BASIS)







BASIS)






COMPONENT NAME




NUMBER

20

21

22

23

24

25

26

27

28







99

1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52
53 Cost to be allocated














































53
54 UCM














































54






































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)
















































48-522















































Rev. 1

Sheet 15: E Pooled

MM-YY



















FORM CMS-287-21



















4895
ALLOCATION OF POOLED COSTS FOR DOUBLE ALLOCATION METHOD

































HOME OFFICE



PERIOD:



SCHEDULE E






































NUMBER:




FROM:

____________







































_________________
TO: ____________
















































































































ALLOCATION













































STATISTICS



CAPITAL RELATED NON-CAPITAL RELATED





















(ENTER ALLOCATION CRC- CRC- SALARIES SAL & WAGES ALL OTHER INTEREST

















BASIS) RATIO B&F ME OF OFFICERS OF OTHERS NON-CAPITAL INCOME

















1 2 3 4 5 6 7 8
1 Healthcare Provider Components














































1
2 Non-Healthcare Components














































2
3 Region / Division Components














































3
4 Total














































4
















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4806 THROUGH SECTION 4806.10.)
















































Rev. 1















































48-523

Sheet 16: E-1 Pooled

4895



















FORM CMS-287-21



















MM-YY
ALLOCATION OF POOLED COSTS TO COMPONENTS

































HOME OFFICE



PERIOD:



SCHEDULE E-1






































NUMBER:




FROM:

____________







































_________________
TO: ____________































































































PART I - HEALTHCARE PROVIDER COMPONENTS

































































ALLOCATION













































STATISTICS



CAPITAL RELATED NON-CAPITAL RELATED





















(ENTER ALLOCATION CRC- CRC- SALARIES SAL & WAGES ALL OTHER INTEREST

















BASIS) RATIO B&F ME OF OFFICERS OF OTHERS NON-CAPITAL INCOME







COMPONENT NAME






CCN
1 2 3 4 5 6 7 8
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































PART II - NON-HEALTHCARE COMPONENTS

































































ALLOCATION













































STATISTICS



CAPITAL RELATED NON-CAPITAL RELATED





















(ENTER ALLOCATION CRC- CRC- SALARIES SAL & WAGES ALL OTHER INTEREST

















BASIS) RATIO B&F ME OF OFFICERS OF OTHERS NON-CAPITAL INCOME







COMPONENT NAME








1 2 3 4 5 6 7 8
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































PART III - REGION / DIVISION COMPONENTS

































































ALLOCATION













































STATISTICS



CAPITAL RELATED NON-CAPITAL RELATED



















REGIONAL
(ENTER ALLOCATION CRC- CRC- SALARIES SAL & WAGES ALL OTHER INTEREST















HO
BASIS) RATIO B&F ME OF OFFICERS OF OTHERS NON-CAPITAL INCOME







COMPONENT NAME






NUMBER
1 2 3 4 5 6 7 8
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52


















































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4806.20 THROUGH 4806.23.)
















































48-524















































Rev. 1

Sheet 17: F SumCap

MM-YY



















FORM CMS-287-21



















4895
SUMMARY OF CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE F






































NUMBER:




FROM:

____________







































_________________
TO: ____________































































































PART I - HEALTHCARE PROVIDER COMPONENTS






























































































TOTAL
















































CAPITAL

































DIRECT



FUNCTIONAL



POOLED



COST














COMPONENT NAME












CCN



1



2



3



4


1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































PART II - NON-HEALTHCARE COMPONENTS






























































































TOTAL
















































CAPITAL

































DIRECT



FUNCTIONAL



POOLED



COST














COMPONENT NAME

















1



2



3



4


1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































PART III - REGION / DIVISION COMPONENTS






























































































TOTAL
















































CAPITAL




























REGIONAL



DIRECT



FUNCTIONAL



POOLED



COST














COMPONENT NAME












HO NUMBER



1



2



3



4


1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52








































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4807 THROUGH SECTION 4807.13.)
















































Rev. 1















































48-525

Sheet 18: F-1 SumNon-Cap

4895



















FORM CMS-287-21



















MM-YY
SUMMARY OF NON-CAPITAL RELATED COSTS

































HOME OFFICE



PERIOD:



SCHEDULE F-1






































NUMBER:




FROM:

____________







































_________________
TO: ____________































































































PART I - HEALTHCARE PROVIDER COMPONENTS





























































SALARIES ALL OTHER NON-CAPITAL COSTS TOTAL
















SUBTOTAL


SUBTOTAL ALL NON-CAPITAL













DIRECT FUNCTIONAL POOLED SALARIES DIRECT FUNCTIONAL POOLED OTH NON-CAP COST





COMPONENT NAME




CCN
1 2 3 4 5 6 7 8 9
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































PART II - NON-HEALTHCARE COMPONENTS





























































SALARIES ALL OTHER NON-CAPITAL COSTS TOTAL
















SUBTOTAL


SUBTOTAL ALL NON-CAPITAL













DIRECT FUNCTIONAL POOLED SALARIES DIRECT FUNCTIONAL POOLED OTH NON-CAP COST





COMPONENT NAME






1 2 3 4 5 6 7 8 9
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51


















































PART III - REGION OFFICE / DIVISION COMPONENTS





























































SALARIES ALL OTHER NON-CAPITAL COSTS TOTAL











REGIONAL



SUBTOTAL


SUBTOTAL ALL NON-CAPITAL











HO
DIRECT FUNCTIONAL POOLED SALARIES DIRECT FUNCTIONAL POOLED OTH NON-CAP COST





COMPONENT NAME




NUMBER
1 2 3 4 5 6 7 8 9
1















































1
2















































2
3















































3
4















































4
5















































5




































































































50















































50
51 Total














































51
52 Grand Total














































52








































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4807.20 THROUGH SECTION 4807.23.)
















































48-526















































Rev. 1

Sheet 19: G

MM-YY
















FORM CMS-287-21
















4895
BALANCE SHEET




















HOME OFFICE



PERIOD:



SCHEDULE G

























NUMBER:




FROM:

____________


























_________________
TO: ____________





































































































AMOUNT









1
























2











































ASSETS


































CURRENT ASSETS

































1 Cash on hand and in banks

































1
2 Temporary investments

































2
3 Notes receivable

































3
4 Accounts receivable

































4
5


































5
6 Less: allowances for uncollectible notes and accounts receivable

































6
7 Inventory

































7
8 Prepaid expenses

































8
9


































9
10 Total current assets

































10


FIXED ASSETS

































11 Land

































11
12 Land improvements

































12
13
Less: accumulated depreciation
































13
14 Buildings

































14
15
Less: accumulated depreciation
































15
16 Leasehold improvements

































16
17
Less: accumulated depreciation
































17
18 Fixed Equipment

































18
19
Less: accumulated depreciation
































19
20 Automobiles and trucks

































20
21
Less: accumulated depreciation
































21
22 Major movable equipment

































22
23
Less: accumulated depreciation
































23
24 Minor equipment non-depreciable

































24
25


































25
26 Total fixed assets

































26


OTHER ASSETS

































27 Investments

































27
28 Deposits on leases

































28
29 Due from owners/officers

































29
30


































30
31 Total other assets

































31
32 Total assets

































32








































LIABILITIES


































CURRENT LIABILITIES

































33 Accounts payable

































33
34 Salaries, wages, and fees payable

































34
35 Payroll taxes payable

































35
36 Notes and short-term loans payable

































36
37 Deferred income

































37
38 Accelerated payments

































38
39


































39
40 Total current liabilities

































40


LONG TERM LIABILITIES

































41 Mortgage payable

































41
42 Notes payable

































42
43 Unsecured loans

































43
44


































44
45 Total long term liabilities

































45
46 Total liabilities

































46



CAPITAL
































47 Retained earnings

































47
48 Total liabilities and retained earnings

































48








































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4808 THROUGH SECTIO 4808.10.)



































Rev. 1


































48-527

Sheet 20: G-1

4895
















FORM CMS-287-21
















MM-YY
STATEMENT OF REVENUES AND EXPENSES




















HOME OFFICE



PERIOD:



SCHEDULE G-1

























NUMBER:




FROM:

____________


























_________________
TO: ____________











































































DESCRIPTION
























AMOUNT









1
























2



1 Total operating revenue

































1
2 Less: Operating expenses

































2
3 Operating profit or (loss)

































3

Other income:


































4 Contributions, donations, bequests, etc.

































4
5 Interest income

































5
6 Purchase discounts

































6
7 Rebates and refunds of expenses

































7
8 Parking lot receipts

































8
9 Rental income

































9
10


































10
11


































11
12


































12
13


































13
14


































14
15 Total other income

































15

Other expenses:


































16


































16
17


































17
18


































18
19


































19
20


































20
21 Total other expenses

































21
22 Net income or loss for the period

































22


















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4808.20.)



































48-528


































Rev. 1
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