Form Rpie-2016 - Real Property Income And Expense Worksheet And Instructions For Adult Care And Nursing Home Facilities Page 14
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16RPIE-2016-A - Real Property Income & Expense Form - Adult Care / Nursing Home Facilities Only
Page 2
sECtIoN h - LEAsE AND oCCUPANCY INFoRMAtIoN
1.
Does the tenant lease the entire property?
❑ Yes
❑ No
2.
Does the tenant pay utility expenses?
❑ Yes
❑ No
3.
Does the tenant pay maintenance and repair expenses?
❑ Yes
❑ No
4.
Does the tenant pay property tax for the space occupied?
❑ Yes
❑ No
5.
What is the Annual Rent paid to the Property Owner?
______________
6.
Is the net lessee or owner related party subleasing any of the property?
if YEs, then please provide responses to questions 6a-c.
a)
What is the Square Footage?
______________
b)
What is the Use of Space?
______________
c)
What is the Annual Rent?
______________
7.
Are you filing as ground lessor?
if YEs, then please respond to question 7a
a)
What is the Ground Lease Amount that you are receiving?
______________
sECtIoN I - REPoRtING PERIoD
1.
The 2016 income and expense statement is for a:
The 2015 income and expense statement is for a:
The 2014 income and expense statement is for a:
❑
❑
❑
❑
❑
❑
❑
❑
❑
Calendar Year
Fiscal Year
Partial Year
Calendar Year
Fiscal Year
Partial Year
Calendar Year
Fiscal Year
Partial Year
2. Indicate the period covered in this statement:
Indicate the period covered in this statement:
Indicate the period covered in this statement:
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
From ________ / 2016
To ________ / 2016
From ________ / 2015
To ________ / 2015
From ________ / 2014
To ________ 2014
3. Name of the Adult Care / Nursing Home Facility:_____________________________________________________________________
4. For 2014
4a. Total # of Beds: __________
4b. Potential Patient Days: __________
4c. Actual Patient Days: __________
For 2015
4a. Total # of Beds: __________
4b. Potential Patient Days: __________
4c. Actual Patient Days: __________
For 2016
4a. Total # of Beds: __________
5. Patient Mix
(Must Total 100%)
5a. Medicare Part A: ______% 5b. Medicaid: ______% 5c: Private & Other: ______% 5d: Managed Care: ______% 5e: Assisted Living: _______%
6. Potential Patient Days (2016) __________
6a. Medicare Part A: ________ 6b. Medicaid: ________ 6c: Private & Other: ________ 6d: Managed Care: ________ 6e: Assisted Living: ________
7. Actual Patient Days (2016) __________
7a. Medicare Part A: ________ 7b. Medicaid: ________ 7c: Private & Other: ________ 7d: Managed Care: ________ 7e: Assisted Living: ________
8. Overall Occupancy Rate for 2016
_____________%
8a. Medicare Part A: ______% 8b. Medicaid: ______% 8c: Private & Other: ______% 8d: Managed Care: ______% 8e: Assisted Living: _______%
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