RD 442-3 Balance Sheet

American Rescue Plan Act Emergency Rural Health Care (ERHC) Grant Program

RD 442-3

American Rescue Plan Act Emergency Rural Health Care Grant Program

OMB: 0575-0200

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FORM APPROVED
OMB No. 0575-0015
OMB No. 0572-0137
OMB No. 0575-0200
Exp. Date: 01/31/2022

Position 3

Form RD 442-3
(Rev. 3-97)

Name

BALANCE SHEET

Address

ASSETS

Month Day

CURRENT ASSETS

Current Year

1. Cash on hand in Banks
2. Time deposits and short-term investments
3. Accounts receivable
4. Less: Allowance for doubtful accounts
5. Inventories
6. Prepayments
7.
8.
9.
Total Current Assets (Add 1 through 8)

Year

Month Day

Prior Year

Year

(

) (

)

(

) (

)

FIXED ASSETS

10. Land
11. Buildings
12. Furniture and equipment
13.
14.
Less: Accumulated depreciation
15. Net Total Fixed Assets (Add 10 through 14)
OTHER ASSETS

16.
17.
18.

Total Assets (Add 9, 15, 16 and 17)
LIABILITIES AND EQUITIES
CURRENT LIABILITIES

19. Accounts payable
20. Notes payable
21. Current portion of USDA note
22. Customer deposits
23. Taxes payable
24. Interest payable
25.
27.

26.

Total Current Liabilities (Add 19 through 26)

LONG-TERM LIABILITIES

28. Notes payable USDA
29.
30.
31.
Total Long-Term Liabilities (Add 28 through 30)
32.
Total Liabilities (Add 27 and 31)
EQUITY

33. Retained earnings
34. Memberships
35.
Total Equity (Add lines 33 and 34)
36.
Total Liabilities and Equity (Add lines 32 and 35)
CERTIFIED CORRECT

Date

Appropriate Official (Signature)
RD 442-3 (Rev. 3-97)

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information
subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this
information collection is 0575-0015; 0572-0137, and 0575-0200. Public reporting for this collection of information is estimated to be approximately 1 hour per response, including the
time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, completing, and reviewing the collection of information. All responses to
this collection of information are voluntary. However, in order to obtain or retain a benefit, the information in this form is required by 7 CFR 1942-A, Community Facility Loans; 7 CFR
1782, Servicing of Water Programs Loans and Grants, and Section 1002 of the American Rescue Plan Act. Rural Development has no plans to publish information collected under the
provisions of this program. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:
Information Collection Clearance Officer, Rural Development Innovation Center, Regulations Management Division at [email protected]


File Typeapplication/pdf
File TitleBalance Sheet
File Modified2022-01-12
File Created2022-01-12

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