Form Av-11 - Addendum To Form Av-10 - Ccr Center
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Continuing Care Retirement Center
AV-11
Web
Addendum to Form AV-10
PRINT
CLEAR
12-11
County of
, NC
Year
Full Name of Owner
Facility Name
Facility Address
City
State
Zip Code
Home Telephone Number
Work Telephone Number
Ext.
Cell Phone Number
Fill in applicable boxes:
►
Yes
No
Is the facility exempt from North Carolina income tax per Article 4 of Chapter 105 of the NC Statutes?
►
Yes
No
Are all of the facility revenues, less operating and capital expenses, applied to providing uncompensated goods and services
to the elderly and to the local community, or are applied to an endowment or a reserve for those purposes?
►
Yes
No
Does the facility have an active program to generate funds through one or more sources such as gifts, grants, trusts, bequests,
endowments, or an annual giving program to assist the retirement facility in serving persons who might not be able to reside
there without financial assistance or subsidy?
Does the facility serve all residents without regard to the resident’s ability to pay?
►
Yes
Attach all relevant documentation to support the claim. Complete the Affirmation section at the end of the form. You do not have to fill
out the rest of the form.
►
No
You must fill out the rest of the form.
Part 1. Resident Revenue
Total Resident Revenue - As Disclosed in Most Recent Audited Financial Statement
(Includes all monthly service fees, fees for service charges, amortized entry fee income
for the year, and any fees associated with living in the facility collected that would
not otherwise be amortized into income for the year. Excludes investment income,
1.
contributions and income from non-resident sources.) Attach Relevant Sections of
the Most Recent Audited Financial Statements.
Part 2. Charity Care
(a) Unreimbursed Health Care
(From Medicare/Medicaid or third party cost reports, internal resident assistance
data certified by the facility, or audited financial statements that show amount of
(a)
unreimbursed costs) Attach applicable pages of cost reports.
(b) Unreimbursed Housing and Services
(From internal assistance reports (Lyons software or spreadsheet) certified by the
facility, and/or audited statements which show amount of unreimbursed costs, and/
(b)
or as disclosed in most recent audited financial statement)
Total Charity Care
(Add lines a + b from Part 2.)
2.
0
Part 3. Community Benefits
(Amounts claimed are to be taken from audited financial statements which either footnote the amount or disclose the amount in the statement of
operations as a line item, and/or can be taken from documented receipt letters from entities receiving the service, donation or volunteer service,
and/or as documented in the Lyons Software or similar spreadsheet program certified by the facility. The amounts are limited to actual expenses
incurred by the facility to perform the service or provide the donation.)
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