Lic 403 Balance Sheet Details

The California Balance Sheet is a document that gives an overview of the state's financial health. It includes data on revenues, expenditures, and debt. The balance sheet also provides information about the state's assets and liabilities for things like pensions or other post-employment benefits, deferred outflows of resources from pension plans, contingent liabilities such as lawsuits or claims against the government, long term investments in securities including Treasury bonds and State certificates of indebtedness as well as cash balances. The report also shows how much money is owed to providers who provide goods and services to the state such as vendors providing office supplies or food items at prisons.

Before you fill out california balance sheet, you will need to know more concerning the type of form you'll work with.

QuestionAnswer
Form NameCalifornia Balance Sheet
Form Length2 pages
Fillable?Yes
Fillable fields40
Avg. time to fill out8 min 30 sec
Other namesdss lic 403, what is a balance sheet, lic information sheet, lic 403a form

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

 

 

 

 

IMPORTANT

BALANCE SHEET

-

Before completing, see reverse for

As of__________________________

 

instructions.

-

Attach LIC 403a.

(ENTER CURRENT DATE)

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTITY NAME:

 

FACILITY NAME:

 

APP./LIC. NO.

 

 

 

 

 

 

 

 

 

 

 

 

ASSETS

 

 

 

 

 

 

CURRENT ASSETS

 

 

 

 

 

 

 

1.

Cash on hand

. . . . . . . . . . . . . . . . . . . . . . .

$_____________________

 

 

 

 

2.

Cash in Financial Institutions

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

3.

CD’s & Other Like Accounts

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

4.

Short-Term Receivables & Notes . . . .

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

5.

Stocks & Bonds

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

6.

Other Current Assets

 

______________________

 

 

 

 

. . . . . . . . . . . . . . . . . . . . . . .

 

 

 

 

7.

TOTAL CURRENT ASSETS

(add lines 1 through 6) . . . .

. . .

. . . . . . . . . . . . . . . . . . . . . . . 7

$

 

__________________

 

 

LONG-TERM ASSETS

 

 

 

 

 

 

 

8.

Real Property

. . . . . . . . . . . . . . . . . . . . . . .

$

____________________

 

 

 

 

9.

Land (other than included in above) . .

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

10.

Improvements

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

11.

Equipment

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

12.

Furniture & Fixtures

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

13.

Other Long-Term Assets:

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

14.

______________________________

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

15.

______________________________

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

16.

______________________________

 

______________________

 

 

 

 

. . . . . . . . . . . . . . . . . . . . . . .

 

 

 

 

17.

TOTAL LONG-TERM ASSETS

(add lines 8 through 16)

17

$

 

__________________

 

18.

TOTAL ASSETS

(add lines 7 and 17)

 

$

__________________

 

 

 

LIABILITIES AND EQUITY

 

 

 

 

 

LIABILITIES

 

 

 

 

 

 

 

19.

Credit Accounts (open, revolving and installment)

$

____________________

 

 

 

 

20.

Salaries & Wages Payable

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

21.

Taxes Payable

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

22.

Other Payables

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

23.

Mortgages

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

24.

Auto Loans

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

25.

Equipment Loans

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

 

 

 

26.

Other Notes Payable

. . . . . . . . . . . . . . . . . . . . . . .

______________________

 

__________________

 

27.

TOTAL LIABILITIES

(add lines 19 through 26)

. . . . . . . . . . . . . . . . . . . . . . 27

$

__________________

 

 

EQUITY

 

 

 

 

 

 

 

28.

Equity

(subtract line 27 from line 18)

28

$

 

 

 

__________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I declare under penalty of perjury that the foregoing and any attachments are true and correct.

PREPARED BY:

TITLE:

APPLICANT/LICENSEE SIGNATURE:

DATE:

LIC 403 (7/11)

PAGE 1 OF 2

BALANCE SHEET

GENERAL INFORMATION: To complete the Balance Sheet LIC 403, first complete the LIC 403a, Balance Sheet Supplemental Schedule. The LIC 403a is a worksheet to be used in compiling the detailed information which is then totaled and displayed on the Balance Sheet, LIC 403. Submit the LIC 403a attached to the LIC 403.

Each applicant/licensee (sole proprietorship, partnership or corporation) must submit a LIC 403, and a LIC 403a. Information to be reported is to disclose all the entity’s assets and liabilities, not just those related to the operation of the care facility.

FOR SOLE PROPRIETORSHIPS - For a facility operated by a husband or wife individually, information reported must pertain to both, such as individual credit card balances which are listed either solely under one name or under both the husband and wife, and which may be unrelated to the facility’s actual operation or the person who will actually operate the facility.

FOR GENERAL PARTNERS - In addition to financial statements for the partnership, each general partner must file a personal Balance Sheet, LIC 403, accompanied with a LIC 403a, to reflect their individual financial position.

Information shown on the LIC 403 and LIC 403a is subject to verification. Additional documentation may be requested to support any or all of the Balance Sheet amounts reported.

INSTRUCTIONS: Include the required information at the top of this form to identify: 1) current date for the Balance Sheet, 2) entity name, (this is the sole proprietorship, partner, partnership or corporate name for whom the information is being reported) 3) facility name and 4) application/license number. Transfer the totals from the worksheet LIC 403a to the corresponding lines on the LIC 403. Below is a brief description of the type of information to be contained on each line.

ASSETS

Line #

1.Cash on hand, not deposited in a financial institution.

2.Cash in checking accounts.

3.CD’s, savings account(s) and all other like accounts.

4.Revenues receivable and all short-term notes receivable (less than one year).

5.Stocks, bonds or other securities.

6.Other current assets readily converted to cash, such as the cash surrender value of whole life insurance policies.

7.Add the amounts on lines 1 through 6 and enter here.

8.Real property is buildings, land and structures.

9.Land (developed or undeveloped) not already included on line 8.

10.Improvements to real property or leasehold improvements as appropriate.

11.Business or personal equipment, (other than that being leased).

12.Business or personal furniture and fixtures, as appropriate, (other than that being leased).

13-16. Other Long-Term Assets (Autos, motor homes inventory, etc.)

17.Add the amounts reported on lines 8 through 16 and enter here.

18.Add the amounts on line 7 and line 17 and enter here.

LIABILITIES

19.Credit Accounts (Open, Revolving and Installment).

20.Salaries, wages, bonuses and other benefits payable.

21.Federal, state or local income, sales or payroll taxes.

22.Other notes or payables not included above.

23.Current balances for all of the outstanding mortgages.

24.Vehicle loans.

25.Loans payable for furniture and equipment.

26.Other long-term notes or payables.

27.Add the amounts on lines 19 through 26 and enter here.

EQUITY

28.The equity is the difference between your total assets and total liabilities. Subtract line 27 from line 18 and enter here.

SIGNATURE BLOCK

The name of the preparer is to be printed in the space provided. The applicant or licensee is required to sign this form attesting to the financial information. Failure to sign, date and attest to the accuracy of the information reported on the Balance Sheet (LIC 403) shall constitute non-compliance and the rejection of this report.

LIC 403 (7/11)

PAGE 2 OF 2

How to Edit California Balance Sheet

We've used the efforts of the best computer programmers to build the PDF editor you are about to apply. The application allows you to fill out the lic403a file easily and don’t waste valuable time. All you should undertake is adhere to these particular simple instructions.

Step 1: Choose the orange button "Get Form Here" on the webpage.

Step 2: You can now change your lic403a. This multifunctional toolbar will let you add, erase, customize, and highlight text or undertake other commands.

You should type in the next information to create the lic403a PDF:

entering details in what is a balance sheet step 1

Type in the information in the TOTAL LONG-TERM ASSETS, (add lines 8 through, (add lines 7 and, LIABILITIES AND EQUITY, LIABILITIES, (add lines 19 through 26) , and EQUITY field.

part 2 to entering details in what is a balance sheet

You'll have to write particular information inside the box EQUITY, (subtract line 27 from line 18) , I declare under penalty of perjury, PREPARED BY:, TITLE:, APPLICANT/LICENSEE SIGNATURE:, DATE:, LIC 403 (7/11), and PAGE 1 OF 2.

part 3 to completing what is a balance sheet

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Step 4: Get as much as a couple of copies of your document to stay away from any specific potential difficulties.