NURSING HOME INCOME QUESTIONNAIRE
INCOME QUESTIONNAIRE FOR 36 MONTHS:
NAME & LOCATION OF PROPERTY
FROM
2006
TO
2008____
OWNER AND ADDRESS OF RECORD
BED RATES:
GROSS FLOOR AREA ___________________ TOTAL # OF ROOMS___________________ TOTAL # OF PRIVATE BEDS ____________ TOTAL # OF SEMI-PRIVATE BEDS _______ TOTAL # OF SUBSIDIZED BEDS__________ TOTAL # OF BEDS _____________________ ANNUAL OCCUPANCY RATE ____________ PRIVATE PAY: 1. PRIVATE ROOM RATE ___________ 2. SEMI-PRIVATE ROOM ____________ GOVERNMENT SUBSIDIZED ROOM RATE ____________ SERVICES PROVIDED IN DAILY RATE________________ (ATTACH LIST & EXPLAIN)__________________________ ____________________________________________________ ____________________________________________________ 2008 2007 2006 ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________
REVENUE:
1. 2. 3. 4. 5. ROOM & BOARD MEDICAL & NONMEDICAL ANCILLARY SERVICES OTHER INCOME LOSS DUE TO BAD DEBT EFFECTIVE GROSS INCOME
OPERATING EXPENSES: 1. ADMINISTRATION 2. MANAGEMENT FEE 3. DIETARY 4. LAUNDRY & LINEN 5. HOUSEKEEPING 6. PLANT OPERATIONS 7. SOCIAL SERVICES & ACTIVITIES 8. OTHER PATIENT CARE 9. NURSING 10. ANCILLARY 11. NON-REIMBURSABLE 12. MISCELLANEOUS 13. INSURANCE 14. RESERVES FOR REPLACEMENT 15. OTHER (LIST) 16. TOTAL OPERATING EXPENSES NET OPERATING INCOME CAPITAL EXPENSES: 1) FURNITURE FIXTURES & EQUIPMENT 2) REAL ESTATE TAXES 3) MORTGAGE PAYMENT 4) BUILDING DEPRECIATION 5) CAPITAL IMPROVEMENTS
MORTGAGE/SALES INFORMATION:
1. Is there a current mortgage on this property? 2. If Yes, please provide the following data: ________________________________ Name of Mortgagee ___________________ Term of Mortgage Yes _________ No _________ ___________________ Mortgage Amount ___________________ Date 1st Payment ________________ Interest Rate ________________ Monthly Payment
3. Please provide: Date Purchased______________ Consideration______________ I declare, under the penalties of perjury, that the contents of this form and all the accompanying schedules and statements have been examined by me and are true, correct, and complete to the best of my knowledge, information, and belief. __________________________________ Signature __________________________________ Print/Type Name of Signer ________________________ Title of Signer _______________ Phone Number ______________ Date RP-68 (Rev. 12/03rs)