Facility Name __________________________ VPN or Provider ID_______________ Balance Sheet Date (MO-DA-YR) ______________________ 2014 HCF-4 SCHEDULE 5: ANALYSIS OF MORTGAGES AND NOTES PAYABLE 1. Mortgages and Notes Supporting Fixed Assets 1 Rel. Date Mort. No.of Original Mort. Amort.of Lender Party Acquired Due Date Months Monthly Mortgage Acq. Mort. Acq Bal. Principal Bal. Rate Interest Period Name Y/N Mo-Da-Yr Mo-Da-Yr Amort. Payments Amount Costs Costs 1/1/2014 Payment 12/31/2014 % Expense Expense* 1st Mortgage 2nd Mortgage 3rd Mortgage 4th Mortgage Chattel Note Chattel Note Capital Lease XXXXX XXX XXXXX XXXXX XXXX XXXXX XXXX XXXXX XX Totals (a) (b) (c) Total Fixed Interest a + b + c (4520.8) = $___________ 2. Working Capital Debt 1 Balance Interest Rate % # Interest Expense2 Lender Name Rel.PartyY/N Balance 1/1/2014 New Loan Amount Start (Mo-Da-Yr) Principal Payment 12/31/2014 1 2 3 Total Working Capital Interest (4430.0)2= $____________________ Total Working Capital Debt (2100.0 less 2160.0) $____________________ 1 This schedule should include all mortgages and notes payable whether or not interest expense is incurred. Each new note should be reported with all information items filled in completely. New notes or enhancements of existing notes should be reported on a new line separately. 2 The sum of the working capital interest expense. * See Instructions
Facility Name __________________________ VPN or Provider ID_______________ Balance Sheet Date (MO-DA-YR) ______________________ 2014 HCF-4 SCHEDULE 5: ANALYSIS OF MORTGAGES AND NOTES PAYABLE 1. Mortgages and Notes Supporting Fixed Assets 1 Lender Name Rel. Party Y/N Date Mort. Acquired Mo-Da-Yr Due Date Mo-Da-Yr No.of Months Amort. Monthly Payments Original Mortgage Amount Mort. Acq. Costs Amort.of Mort. Acq Costs Bal. 1/1/2014 Principal Payment Bal. 12/31/2014 Rate % Interest Expense Period Expense* 1st Mortgage 2nd Mortgage 3rd Mortgage 4th Mortgage Chattel Note Chattel Note Capital Lease Totals XXXXX XXX XXXXX XXXXX XXXX XXXXX XXXX XXXXX XX (a) (b) (c) Total Fixed Interest a + b + c (4520.8) = $___________ 2. Working Capital Debt 1 # Lender Name Rel.PartyY/N Balance 1/1/2014 New Loan Amount Start (Mo-Da-Yr) Principal Payment Balance 12/31/2014 Interest Rate % Interest Expense2 1 2 3 Total Working Capital Interest (4430.0)2= $____________________ Total Working Capital Debt (2100.0 less 2160.0) $____________________ 1 This schedule should include all mortgages and notes payable whether or not interest expense is incurred. Each new note should be reported with all information items filled in completely. New notes or enhancements of existing notes should be reported on a new line separately. 2 The sum of the working capital interest expense. * See Instructions
2014-HCF-4.docx