Montana Form Id-Nh - Nursing Home Income And Expense Reporting Form

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MONTANA

Clear Form

Form ID-NH

Rev 09 13

Nursing Home

Income and Expense Reporting Form

Property Information

Property Owner ______________________________________________

Geocode _____________________________________

Property Address _____________________________________________

Doing Business As (DBA) or

Building Name _________________________________

Mailing Address ______________________________________________

Income and Expense Data

Rents received as of 12/31/ ____________

Please round to nearest dollar

1. Apartments or cottages ............................................................................................................................................$ ____________

2. Full-care ...................................................................................................................................................................$ ____________

3. Assisted living ..........................................................................................................................................................$ ____________

4. Other rentals (specify) ______________________________________________________________________ $ ____________

5. Parking rental ...........................................................................................................................................................$ ____________

6. Loss due to vacancy and/or collection .....................................................................................................................$ ____________

7. Other income and reimbursements..........................................................................................................................$ ____________

8. Amount of rentals subsidized by government(s) ......................................................................................................$ ____________

Expenses

9. Advertising ...............................................................................................................................................................$ ____________

10. Cleaning ...................................................................................................................................................................$ ____________

11. Commissions ...........................................................................................................................................................$ ____________

12. Insurance .................................................................................................................................................................$ ____________

13. Legal and accounting fees .......................................................................................................................................$ ____________

14. Management (cost of administering the leases) ......................................................................................................$ ____________

15. Repairs.....................................................................................................................................................................$ ____________

16. Supplies ...................................................................................................................................................................$ ____________

17. Property taxes ..........................................................................................................................................................$ ____________

18. Utilities .....................................................................................................................................................................$ ____________

19. Other (describe) ___________________________________________________________________________ $ ____________

20. Payroll associated with property (except management) ..........................................................................................$ ____________

21. Snow/trash removal and landscape maintenance ...................................................................................................$ ____________

22. Maintenance (describe) _____________________________________________________________________

________________________________________________________________________________________ $ ____________

23. Reserves for replacement ........................................................................................................................................$ ____________

24. Security ....................................................................................................................................................................$ ____________

Signature

_________________________________________________

_________________________

_____________________________

Signature of Owner or Preparer

Date

SSN or FEIN

____________________________________________________________________________

_____________________________

Print Name and Title

Contact Phone Number

____________________________________________________________________________