Consultant Name: Consultant Phone: DATA TO COMPLETE AHCA S FINANCIALS ALF LICENSING

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Rose Robbins
5 years ago
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1 DATA COLLECTION SHEET 2010 by Caregiver Consulting, Inc. (CCI) All rights reserved any use of DATE: this information in any way for any reason is prohibited without the express written permission of CCI. Consultant Name: Consultant Phone: FAX WHEN COMPLETED TO: CAREGIVER CONSULTING, INC DATA TO COMPLETE AHCA S FINANCIALS ALF LICENSING Facility Name: Address: City: FL. Zip Code Telephone: Fax: County Where Facility is Located: Call CASZIE HART at if you have questions. Facility License Type: Standard LNS LMH ECC Total No. of Beds: No. Private Beds: No. of Current Residents: New Owner s Name Phone: Fax: New Owner s Administrator s Name: Old Owner s Name (if CHOW) Old Owner s Corporation Bill of Sale Amt. Payment Method: IMPORTANT NOTICE THE FINANCIALS WILL BE DONE IN HOURS, AFTER THIS FORM IS RETURNED TO US FULLY COMPLETED. WE REQUIRE A 50% DEPOSIT IN ADVANCE. THE 50% BALANCE IS DUE WHEN THE FINANCIALS ARE COMPLETED. FINAL PAYMENT MUST BE MADE IN CASH, OR BY CREDIT CARD OR DEBIT CARD. A CREDIT CARD AUTHORIZATION IS ON THE NEXT PAGE. THERE IS NO COST FOR CORRECTIONS. You will know how much AHCA requires you to have when the forms are prepared. 1

2 COST AND CERTIFICATION OF EXPECTED REVENUE AND EXPENSES COST OFSERVICE: New Prof of Financial Ability to Operate + Notes & Assumptions Beds $ Beds $ Beds $1, Beds $ Beds $1, Beds $1, Beds $ Beds $1, Beds $1, Beds $ Beds $1, Beds $1, Beds $ Beds $1, Beds $1,850 OPTIONAL SERVICES: We provide the following documents at an additional charge if needed. Administrator Certification (reduces the Cash on Hand required) Letters of Commitment for Contingency Funding Provides for funds to cover unexpected emergencies e.g., hurricane $25.00 $25.00 AHCA compliant Commercial Lease Even if you own the property, you might need to lease it to your business. Purchase Order Needed when giving/selling furniture already purchased to the business CHOW Bifurcated Purchase & Sale Contract CHOW Bill of Sale You need a special bifurcated contract and bill of sale for CHOW STOCK TRANSFER DOCS (certificates, transfer agreement, etc.) $ CERTIFICATION I, the undersigned, certify that the financial information provided herein is true and correct to the best of my knowledge. I understand AHCA might ask for more information or receipts and can deny my application if it determines that any of the information I provide is insufficient or unacceptable. Signature of Owner or Administrator PRINT NAME Date FILL IN BELOW IF YOU WISH TO PAY BY CREDIT OR DEBIT CARD PAYMENT AUTHORIZATION TO CAREGIVER CONSULTING, INC. Amount: Card Type Visa MasterCard Discover Date Expire Phone No. Card Number Name on Card Bill Address City Signature 2 State/Zip Code CCV: (3 digits) [Card billing address ] Date Signed

3 BANK STATEMENTS: When the Proof of Financial Ability to Operate forms are finished they will tell you the amount AHCA requires you to show for Working Capital and Contingency Funding. You will have to send BANK STATEMENTS or BANK LETTERS, IN ENGLISH, DATED THE SAME DAY OR DAY BEFORE YOU SEND YOUR APPLICATION TO AHCA. RESIDENTS MONTHLY PAYMENT Resident Private Pay Medicaid LTC ACS Resident Private Pay Medicaid LTC ACS LIST THE FOLLOWING MONTHLY EXPENSES WITH COMMENTS IF ANY Item Monthly Amt. Comments (if any) Rent/Mortgage Utilities (phone, water, etc.) Insurance (required liability) AHCA requirement for licensing Accountant/Bookkeeper Menu preparation $90.00/Year Repair/Maintenance Security Monitoring Pool Cleaning Lawn Service Equipment lease payment Total Loan, Interest, Years : : : Advertisement Amt. Paid Amt. to be Paid New Website Flyers/Postcards/Brochures Print Media (newspapers, etc.) Broadcast Media 3

4 STATE THE $ AMOUNTS YOU PAID OR EXPECT TO PAY FOR THE ITEMS INDICATED. AHCA MAY ASK FOR RECEIPTS FOR ITEMS LISTED AS ALREADY PAID MAKE SURE YOU HAVE THEM EQUIPMENT OR PROPERTY IMPROVEMENTS ALREADY PURCHASED Site Equipment Fire Alarm/Pull Station Sprinkler System Handicap (handrails, ramps, etc.) New/Modified Windows Bathroom renovations Security System Air Conditioning System Dining Room Equipment Table with chairs Kitchen Equipment Dishwasher Stove Refrigerator Dishes and utensils Living Room Equipment Sofa Chairs Television Television Stand Coffee Table Incidentals 4

5 Bedroom Equipment Beds Linen Towels Lamps Dressers Hampers Caddy Pictures Office Equipment and Furniture Computer Phone and Fax Printer and Copier Desk Chairs : CAREGIVER CONSULTING, INC. Send us an to: caregiverconsulting@hotmail.com Get more valuable information online at: 5

HOME INVENTORY CHECKLIST

HOME INVENTORY CHECKLIST Determining the value of your personal property requires an extensive analysis on your part. You should go through each room of your house and list every piece of furniture and fixture within it. Some