I. IDPH Facility ID Number: II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

Please complete the Real Estate Tax Statement below and forward with a copy of your 2001 real estate tax bill to the Department of Public Aid, Office of Health Finance, 201 South

The cost report will not be considered complete and timely filed until this statement and the corresponding real estate tax bills are filed... BUILDING AND

(12) Are there any salary costs which have been allocated to more than one line on Schedule V (19) Has a schedule for the legal fees reported on the cost report been provided by

action organization? No If YES, have these costs is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attach been properly adjusted out of the cost

action organization? Yes If YES, have these costs is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attach been properly adjusted out of the

Office Expense Employee Benefits & PR Taxes Travel & Seminar Insurance-Property, Liability & Malpractice Total General Administrative Total Operating Expenses

* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s) of the

action organization? YES If YES, have these costs is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attach been properly adjusted out of the