The California Balance Sheet form, officially known as LIC 403, is a financial document required by the California Department of Social Services for entities operating community care facilities. This form captures a comprehensive overview of an entity's assets, liabilities, and equity, ensuring that all financial information is accurately reported. For assistance in completing this important form, click the button below.
The California Balance Sheet form, officially known as LIC 403, plays a crucial role in the financial reporting process for various entities, particularly those involved in community care licensing. This form requires applicants and licensees to provide a comprehensive overview of their financial status by detailing both assets and liabilities. It begins with a section for current assets, where entities must report cash on hand, cash in financial institutions, and other short-term receivables. Following this, the long-term assets section captures the value of real property, equipment, and other significant investments. On the liabilities side, the form outlines obligations such as credit accounts, salaries payable, and mortgages, culminating in a total liabilities figure. The equity section, which reflects the difference between total assets and total liabilities, provides insight into the entity's financial health. Importantly, both the Balance Sheet and its accompanying supplemental schedule, LIC 403a, must be completed and submitted together, ensuring that the reported figures are accurate and verifiable. This structured approach not only aids in compliance with state regulations but also offers a clear financial picture to stakeholders.
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
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.
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.
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.
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.
PAGE 2 OF 2
Completing the California Balance Sheet form is a crucial step in ensuring your financial information is accurately reported. This form provides a comprehensive overview of your entity's assets, liabilities, and equity. After filling out the Balance Sheet, you will need to submit it along with the LIC 403a, which serves as a supplemental schedule detailing the financial data.
What is the California Balance Sheet form?
The California Balance Sheet form, also known as LIC 403, is a financial document required by the California Department of Social Services for applicants and licensees of community care facilities. It provides a snapshot of an entity's financial position by detailing its assets, liabilities, and equity as of a specific date.
Who needs to complete the California Balance Sheet form?
All applicants and licensees, including sole proprietorships, partnerships, and corporations, must complete the California Balance Sheet form. Each entity must submit a LIC 403 along with a supplemental schedule, LIC 403a, which helps compile the detailed financial information that appears on the Balance Sheet.
What information is required on the Balance Sheet?
The Balance Sheet requires detailed information about both current and long-term assets, as well as liabilities. Applicants must report all financial information related to the entity, not just what pertains to the operation of the care facility. This includes cash, receivables, property, loans, and any other financial obligations.
How do I complete the Balance Sheet?
To complete the Balance Sheet, start by filling out the LIC 403a, which serves as a worksheet for gathering necessary financial data. Once the totals are calculated on the LIC 403a, transfer these amounts to the corresponding lines on the LIC 403. Ensure to include identifying information such as the current date, entity name, facility name, and application/license number at the top of the form.
What if I am a sole proprietor?
If you operate as a sole proprietor, the Balance Sheet must include information relevant to both you and your spouse, if applicable. This includes reporting individual credit card balances and other financial details that may not directly relate to the care facility's operations.
Are there specific instructions for general partners?
Yes, general partners must file not only the partnership's financial statements but also their personal Balance Sheets. Each general partner should submit a separate LIC 403 along with a LIC 403a to reflect their individual financial position accurately.
What happens if I do not sign the Balance Sheet?
Failure to sign, date, and attest to the accuracy of the information on the Balance Sheet will result in non-compliance. This may lead to the rejection of the report, which can impact the licensing process for the care facility.
Can additional documentation be requested?
Yes, the information reported on the Balance Sheet and the accompanying LIC 403a is subject to verification. The California Department of Social Services may request additional documentation to support any amounts reported on the Balance Sheet.
Filling out the California Balance Sheet form can be a straightforward process, but there are common mistakes that can lead to complications or even rejection of the application. One significant error is neglecting to complete the LIC 403a, the supplemental schedule. This worksheet is crucial for compiling detailed information about assets and liabilities. Without it, the totals on the Balance Sheet may not accurately reflect the entity's financial position, which could raise red flags during the review process.
Another frequent oversight involves misreporting the entity name and facility name. Applicants sometimes confuse these two, leading to discrepancies that can complicate the application. It is essential to ensure that the names match exactly as they appear on official documents. Any inconsistency could result in delays or the need for additional documentation, which can be avoided with careful attention to detail.
Inaccurate calculations are also a common pitfall. When adding up the total current assets or total liabilities, it is easy to make simple arithmetic errors. This mistake can significantly impact the reported equity, which is derived from the difference between total assets and total liabilities. Double-checking these figures can save time and prevent unnecessary complications.
Moreover, some applicants fail to include all relevant liabilities. It is crucial to report not just the obvious debts, such as mortgages and loans, but also any other payables, such as taxes and salaries owed. Omitting these can paint an incomplete picture of the entity's financial obligations, leading to potential issues with compliance.
Lastly, neglecting to sign and date the form is a critical error that can lead to outright rejection of the application. The signature attests to the accuracy of the information provided, and without it, the submission is incomplete. Ensuring that all required fields are filled out, including the signature block, is essential for a successful application process.
The California Balance Sheet form is a critical document used by applicants and licensees in the health and human services sector. To ensure accurate financial reporting, several additional forms and documents are often required. Below is a list of these documents, each accompanied by a brief description.
These documents work together with the California Balance Sheet form to provide a comprehensive view of an entity's financial standing. Properly completing and submitting these forms is essential for compliance and successful licensing in the sector.
The California Balance Sheet form is a crucial document for reporting financial information for care facilities. It shares similarities with several other financial documents. Here are four such documents and how they relate to the California Balance Sheet:
Understanding these documents can significantly impact financial decisions. Each serves a unique purpose but collectively contributes to a clearer financial picture.
When filling out the California Balance Sheet form, it’s essential to approach the task with care. Here are some important do's and don'ts to keep in mind:
By following these guidelines, you can help ensure that your submission is complete and accurate, making the process smoother for everyone involved.
This is incorrect. The Balance Sheet must disclose all assets and liabilities of the entity, not just those tied to the operation of the facility.
In fact, each applicant or licensee, whether a sole proprietorship, partnership, or corporation, must submit a Balance Sheet and a supplemental schedule.
This is false. Sole proprietorships must include personal financial information, such as credit card balances, on the Balance Sheet.
This is misleading. Information on the Balance Sheet is subject to verification, and additional documentation may be requested.
This is not true. The LIC 403a is essential for compiling the detailed information needed for the Balance Sheet.
Incorrect. The applicant or licensee must sign the form to attest to the accuracy of the information. Failure to do so will lead to non-compliance.
This is a misunderstanding. The Balance Sheet also includes long-term assets and liabilities, providing a comprehensive view of the entity's financial position.
Filling out the California Balance Sheet form is a crucial step for any applicant or licensee involved in community care licensing. Here are key takeaways to ensure you complete it accurately and effectively:
Completing the California Balance Sheet form accurately is essential for compliance and financial transparency. Take the time to ensure all information is correct and complete.