California Balance Sheet (LIC 403) at a glance
What it is: The California Balance Sheet (LIC 403) of the California Department of Social Services Community Care Licensing.
Who signs: The applicant or licensee is required to sign this form attesting to the financial information.
Each applicant/licensee (sole proprietorship, partnership or corporation) must submit a LIC 403, and a LIC 403a.
A filled-in California Balance Sheet (LIC 403) example: a sole proprietor reports cash, equipment and one auto loan
How to fill out California Balance Sheet (LIC 403), box by box
Date, entity name, facility name and application/license number
Include the required information at the top of the 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.
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.
Current assets
Line 1: Cash on hand, not deposited in a financial institution.
Line 2: Cash in checking accounts.
Line 3: CD's, savings account(s) and all other like accounts.
Line 4: Revenues receivable and all short-term notes receivable (less than one year).
Line 5: Stocks, bonds or other securities.
Line 6: Other current assets readily converted to cash, such as the cash surrender value of whole life insurance policies.
Line 7: Add the amounts on lines 1 through 6 and enter here.
Long-term assets
Line 8: Real property is buildings, land and structures.
Line 9: Land (developed or undeveloped) not already included on line 8.
Line 10: Improvements to real property or leasehold improvements as appropriate.
Line 11: Business or personal equipment, (other than that being leased).
Line 12: Business or personal furniture and fixtures, as appropriate, (other than that being leased).
Lines 13-16: Other Long-Term Assets (Autos, motor homes inventory, etc.)
Line 17: Add the amounts reported on lines 8 through 16 and enter here.
Line 18: Add the amounts on line 7 and line 17 and enter here.
Liabilities
Line 19: Credit Accounts (Open, Revolving and Installment).
Line 20: Salaries, wages, bonuses and other benefits payable.
Line 21: Federal, state or local income, sales or payroll taxes.
Line 22: Other notes or payables not included above.
Line 23: Current balances for all of the outstanding mortgages.
Line 24: Vehicle loans.
Line 25: Loans payable for furniture and equipment.
Line 26: Other long-term notes or payables.
Line 27: Add the amounts on lines 19 through 26 and enter here.
Equity
The equity is the difference between your total assets and total liabilities. Subtract line 27 from line 18 and enter here.
Signing the balance sheet
Sign at APPLICANT/LICENSEE SIGNATURE, and fill in PREPARED BY, TITLE and DATE.
The name of the preparer is to be printed in the space provided.
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.
More rules for California Balance Sheet (LIC 403)
Submit the LIC 403a attached to the LIC 403.
To complete the Balance Sheet LIC 403, first complete the LIC 403a, Balance Sheet Supplemental Schedule.
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.
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. Transfer the totals from the worksheet LIC 403a to the corresponding lines on the LIC 403.
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.
Sources
[1] California Balance Sheet (LIC 403) (7/11), California Department of Social Services (the Official source link on this page).
