ࡱ> %` RbjbjNN 4,, xxxxxxx)))8)*U2,0000u11 1TTTTTTT$FVhXH5Tx]3u1u1]3]35Txx00To7o7o7]3Rx0x0To7]3To7o7EhxxG0, ~U )33FkNT0UCFZ=4Z GZxGd1Z1@o7524i21115T5T7R111U]3]3]3]3!&&xxxxxx DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62674A (Rev. 07/08) MODEL BALANCE SHEETSTATE OF WISCONSIN Chapter 50.02(2)(a), Wis. Stats. Page 1 of 2This form may be used when submitting a license application for an Adult Family Home (AFH), a Community Based Residential Facility (CBRF), or a Home Health Agency (HHA). Read instructions on page 2 before completing this form.Name Agency  FORMTEXT      Date Completed  FORMTEXT      Address  FORMTEXT      ASSETSLIABILITIESCurrent AssetsCurrent LiabilitiesCash in Bank FORMTEXT      Accounts Payable FORMTEXT      Other Short Term Investments (e.g., money market, stocks, CDs)  FORMTEXT      Loans Payable (due within 12 months) FORMTEXT      Prepaid Expenses FORMTEXT      Accrued Payroll / Withholding FORMTEXT      Receivables FORMTEXT      Taxes Payable FORMTEXT      Other (Specify.)  FORMTEXT       FORMTEXT      Current Portion of Long Term Debt FORMTEXT       FORMTEXT       FORMTEXT      Other (Specify.)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Total Assets (Current) FORMTEXT      Total Liabilities (Current) FORMTEXT      Fixed AssetsLong Term LiabilitiesVehicles FORMTEXT      Loans Payable (due after 12 months) (e.g., land contract, mortgage, vehicles, bank loans, etc.) FORMTEXT      Furniture and Equipment FORMTEXT      Leasehold Improvements FORMTEXT      Real Estate / Buildings FORMTEXT      Other (Specify.)  FORMTEXT       FORMTEXT      Other (Specify.)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Total Assets (Fixed) FORMTEXT      Total Liabilities (Long Term) FORMTEXT      TOTAL ASSETS (Current plus Fixed)  FORMTEXT      TOTAL LIABILITIES (Current plus Long Term) FORMTEXT      Total Assets must equal the sum total of owner s total liability and owner s equity (net worth).OWNER S EQUITY (NET WORTH)TOTAL ASSETSTOTAL ASSETS FORMTEXT      TOTAL LIABILITIES FORMTEXT      TOTAL LIABILITIES FORMTEXT      OWNER S EQUITY FORMTEXT      OWNER S EQUITY FORMTEXT      TOTAL ASSETS FORMTEXT       F-62674A (Rev. 07/08) Page 2 of 2 MODEL BALANCE SHEET This balance sheet is used when submitting a license application for an Adult Family Home (AFH), a Community Based Residential Facility (CBRF), or a Home Health Agency (HHA). The Model Balance Sheet is a suggested format; however, the same basic information is required when using another format. Other balance sheet formats containing the required information will be accepted. A. What is a balance sheet? What is it used for? A balance sheet is a financial snapshot of you or your business at a given date in time. The balance sheet provides information on what you or your business own (assets), what you or your business owe (liabilities), and your net worth or the value of the business (equity). The term balance sheet is derived from the fact that these accounts must always be in balance. Assets must always equal the sum of liabilities and equity. 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<$Ifgdfkd/$$Ifl4F&x+   z   t0+    44 lapytp'P $$Ifa$gd $$Ifa$gdDLvxz "ȼȎȀseȼQȎȀChx#CJOJQJ^JaJ&j0h&Vhx#5CJUaJhfhx#5OJQJ^Jhejhx#OJQJ^Jh&Vhx#5OJQJ^J3jh&Vhx#5CJOJQJUaJmHnHu&jZ0h&Vhx#5CJUaJh&Vhx#5CJaJ jh&Vhx#5CJUaJhx#5CJaJhx#5OJQJ^J#hhx#5CJOJQJ^JaJLvx $$Ifa$gd&Vp<<$If]pgdfp<$If]pgdf $$Ifa$gd $$Ifa$gd&V $$Ifa$gd <$Ifgdf "1!$x$Ifa$gdG0HkdB1$$Ifl4r&$x+j     z     t0+44 lap(ytf":t:<VXlnpz|Ϳx_R@#j4h&Vhx#CJUaJh]2hx#OJQJ^J0jh&Vhx#CJOJQJUaJmHnHu#j 4h&Vhx#CJUaJh&Vhx#CJaJjh&Vhx#CJUaJhfhx#OJQJ^Jhp'Phx#5OJQJ^Jhx#CJOJQJ^JaJhejhx#OJQJ^JhMwhx#OJQJ^Jhx#OJQJ^JhMwhx#5OJQJ^J :p$4$If^4a$gdp'P$$Ifa$gdp'Pkkd2$$Iflx++ t0+44 laytp'P:<V~]P@3P <<$Ifgd$<<$Ifa$gd&V <<$Ifgdp'Pkd2$$IflF&x+  z   t0+    44 lapytp'P  :<PRT^`bdʼʯʼraUh&Vhx#5CJaJ jh&Vhx#5CJUaJhfhx#5OJQJ^J#j6h&Vhx#CJUaJ#jH6h&Vhx#CJUaJh&Vhx#CJaJhfhx#OJQJ^Jhx#CJOJQJ^JaJh]2hx#OJQJ^J0jh&Vhx#CJOJQJUaJmHnHujh&Vhx#CJUaJ8+ <<$Ifgdp'Pkd4$$Iflr&$x+j  z   t0+44 laytf$<<$Ifa$gd&V:b$<<$Ifa$gd&V <<$Ifgdp'P <<$IfgdbdJ=-$<<$Ifa$gd&V <<$Ifgdp'Pkd07$$Iflr&$x+j  z    t0+44 laytf۳یx۳j\N=N= hthJ`CJOJQJ^JaJh/vCJOJQJ^JaJhp'PCJOJQJ^JaJhx#CJOJQJ^JaJ&j8h&Vhx#5CJUaJh&Vhx#5CJaJhfhx#5OJQJ^JhMwhx#OJQJ^Jh&Vhx#5OJQJ^J3jh&Vhx#5CJOJQJUaJmHnHu jh&Vhx#5CJUaJ&j8h&Vhx#5CJUaJ$<<$Ifa$gd&V <<$Ifgdp'P <<$Ifgd^`4//*gd)!gdG0Hkdg9$$Iflr&$x+j    z     t0+44 lap(ytfF\^`bln%)TYŴsaTG:TGThx#hx#OJQJ^Jhx#h&VOJQJ^Jhx#h!UOJQJ^J#h- h)!5CJOJQJ^JaJ#hx#h)!5CJOJQJ^JaJ#hx#hJ`5CJOJQJ^JaJhf5CJOJQJ^JaJh)!CJOJQJ^JaJ hhG0HCJOJQJ^JaJhG0HCJOJQJ^JaJhmmdCJOJQJ^JaJ hthJ`CJOJQJ^JaJhJ`CJOJQJ^JaJ`bDEyNPfn< h^h`gd)! & Fgd)! E<]Egd)!<gd)! & F gd)! h<^hgd)! <gd)!gd)!$a$gd)!Ytu 0CDEx{$FQ+Pf|̱̤̿~ppppcappWhOJQJ^JUh%Weh)!OJQJ^Jh_ h)!5OJQJ^Jh;h)!5OJQJ^Jh)!OJQJ^Jh!Uh)!5OJQJ^Jhx#h!UOJQJ^Jhx#hN5OJQJ^Jhx#h)!OJQJ^Jhx#hNOJQJ^Jhx#hJ`OJQJ^Jhx#h&VOJQJ^Jhx#hx#OJQJ^J"Can you or your business pay all current and long term debts as they come due? Are you or your business overly indebted, i.e., do your liabilities exceed your assets? B. Terms 1. Current Assets are assets that are usually converted to cash within one year. They include, but are not limited to: Cash  On hand and/or on deposit and is available Short Term Investments  Generally converted easily into cash, e.g., money market funds, U.S. Government securities Receivables  Money that customers owe to you or your business Prepaid Expenses  Items like insurance premiums or rentals which you have already paid but have not yet  used . 2. Fixed Assets are tangible assets with a useful life greater than a year. They include, but are not limited to: Vehicles Furniture and Equipment Leasehold Improvements  improvements on a leased asset that increase the value of the asset Land Buildings 3. Total Assets is the sum total dollar value of current and fixed assets. 4. Current Liabilities are those obligations that are usually paid within 12 months. They include, but are not limited to Accounts Payable Taxes Payable Loans Payable (due within one year) Current Portion of Long Term Debt Accrued Payroll and Withholding (includes any wages or withholdings owed to or for employees that have not yet been paid) 5. Long Term Liabilities are any debts owed that are due more than one year out from the current date, including loans payable, e.g., mortgage, vehicle loan, bank loan. 6. Total Liabilities is the sum total dollar value of current and long term liabilities. 7. Owner s Equity is the amount left when you subtract total liabilities from total assets. Examples: Total Assets Total Liabilities Owner s Equity  $ 100,000 - $ 50,000 $ 50,000 (+) OR Total Assets Total Liabilities Owner s Equity  $ 60,000 - $ 75,000 $ 15,000 (-)C. Total Assets must equal the sum total of owner's total liabilities and owner s equity (net worth). Examples: Total Liabilities Owner s Equity Total Assets  $ 50,000 + $ 50,000 $ 100,000  ORTotal Liabilities Owner s Equity Total Assets  $ 75,000 - $ 15,000 $ 60,000     8PPh t.8Tr\x|칫자입w자입wlh)!5OJQJ^Jh"Fh)!>*OJQJ^Jh)!>*OJQJ^Jh"Fh)!5OJQJ^Jh"Fh)!OJQJ^Jhyh)!5OJQJ^Jhyh)!OJQJ^JhCUh)!5OJQJ^JhJ`OJQJ^Jh_ h)!5OJQJ^Jh)!OJQJ^JhOJQJ^J* *Z80L\ & F gd)! <gd)! gd)! xgd)! & F xgd)! & Fgd)!<gd)!hx^h`gd)! 6r6\z|$ $Ifa$gd)! $Ifgd)!$ $Ifa$gd)! xgd)! 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