Mendota Lutheran Home-2001-0011593 - HFS - State of Illinois

More documents

Recommendations

Info

Mendota Lutheran Home XX General Information Question 12 2001 27 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 27 28 TOTAL General Administration TOTAL Operating Expense 12,166 0 0 0 0 0 0 0 0 0 0 12,166 28 29 (sum of lines 8,16 & 28) 3,350 0 0 0 0 0 0 0 0 0 0 3,350 29 31 of 31
Mendota Lutheran Home XX General Information Question 12 2001 STATE OF ILLINOIS Summary B Facility Name & ID Number Mendota Lutheran Home # 0011593 Report Period Beginning: 01/01/01 Ending: 12/31/01 SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE SUMMARY TOTALS D. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7) 30 Depreciation 2,195 0 0 0 0 0 0 0 0 0 0 2,195 30 31 Amortization of Pre-Op. & Org. 0 0 0 0 0 0 0 0 0 0 0 0 31 32 Interest 0 0 0 0 0 0 0 0 0 0 0 0 32 33 Real Estate Taxes 3,041 0 0 0 0 0 0 0 0 0 0 3,041 33 34 Rent-Facility & Grounds 0 0 0 0 0 0 0 0 0 0 0 0 34 35 Rent-Equipment & Vehicles 0 0 0 0 0 0 0 0 0 0 0 0 35 36 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 36 37 TOTAL Ownership Ancillary Expense E. Special Cost Centers 5,236 0 0 0 0 0 0 0 0 0 0 5,236 37 38 Medically Necessary Transportation 0 0 0 0 0 0 0 0 0 0 0 0 38 39 Ancillary Service Centers 0 0 0 0 0 0 0 0 0 0 0 0 39 40 Barber and Beauty Shops 28,089 0 0 0 0 0 0 0 0 0 0 28,089 40 41 Coffee and Gift Shops 2,003 0 0 0 0 0 0 0 0 0 0 2,003 41 42 Provider Participation Fee 0 0 0 0 0 0 0 0 0 0 0 0 42 43 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 43 44 TOTAL Special Cost Centers GRAND TOTAL COST 30,092 0 0 0 0 0 0 0 0 0 0 30,092 44 45 (sum of lines 29, 37 & 44) 38,678 0 0 0 0 0 0 0 0 0 0 38,678 45 30 of 31
Page 1 and 2: FOR OHF USE Mendota Lutheran Home X
Page 3 and 4: Mendota Lutheran Home XX General In
Page 13: Mendota Lutheran Home XX General In
Page 19 and 20: * Total must agree with the amount
Page 23 and 24: 25 TOTALS Mendota Lutheran Home XX
Page 41 and 42: your facility. Drop-out costs can o
Page 61: Nelson, Tammie 239 $1,482.61 Dietar

Mendota Lutheran Home-2001-0011593 - HFS - State of Illinois

Create successful ePaper yourself

Delete template?

Save as template?