August 28, 2008
Extended repayment schedule request for a corporation or group
To consider an extended repayment schedule (ERS) request for a corporation or group, the following documentation is required:
1. Rationale detailing the request for an extended repayment schedule.
2. An amortization schedule, not to exceed 60 months. This schedule must contain the proposed repayment plan, including length of the plan, dates of repayment, and payment amount broken down between principal and interest for the life of the schedule.
3. The most current balance sheet and income statement on an accrual basis to include an itemized list of account receivables and liabilities. Please include the account payables (including trade payables or daily expenses such as the electric bill, rent, phone, etc.) to support the balance sheet you submit. (See Exhibit 1 for recommended format)
4. A statement of Source and Application of Funds for the period covered by the submitted income statement (See Exhibit 2 for recommended format).
5. Cash flow statements for the period covered by the submitted balance sheets (See Exhibit 3 for recommended format).
6. A projected cash flow statement covering the remainder of the fiscal year (See Exhibit 4 for recommended format).
7. A list of restricted cash funds by amount as of the date of the request and the purpose of each.
8. A list of investments, by type (stock, bond, etc.) amount, and current market value as of the date of the report.
9. A list of notes and mortgages payable by amounts as of the date of the report, and their due dates.
10. A schedule showing amounts due to and from related companies or individuals included in the balance sheets. The schedule should show the names of related organizations or persons and show where the amounts appear on the balance sheet (such as accounts receivable, notes receivable, etc.)
11. A schedule showing types and amounts of expenses (included in the income statements) paid to related organizations. The names of the related organizations should be shown.
12. A copy of one loan application for the amount of the overpayment with a denial letter from the bank. This is only required for extended repayment schedule requests for more than 12 months.
13. Form 1099 for the period of the overpaid dates. If the overpayments occurred in the current year, since the 1099 would not yet be available, the previous year's 1099 should be provided.
Please FAX all documentation to 904-361-0664. You will be advised of the decision after a review of the information is completed.
If you send in the first monthly payment at the same time your fax your ERS documentation, we will discontinue withholding your Medicare claim payments. Please include a statement providing the check number, check amount, and date you mailed the first monthly statement. If you do not submit the first payment, a 30% withhold shall be initiated.
Please send your payment with a copy of this instruction to:
Medicare Part B - Debt Recovery
P.O. Box 44141
Jacksonville, FL 32231-4141
P.O. Box 44141
Jacksonville, FL 32231-4141
EXHIBIT 1 - Certification by Officer/Owner of Debtor
The CMS suggest that both the balance sheet and the income statement include the following certification statement on any financial documents submitted.
Misrepresentation or falsification of any information contained in this balance sheet or income statement may be punishable by fine and/or imprisonment under Federal Law.
CERTIFICATION BY OFFICER/OWNER OF DEBTOR
I hereby certify that I have examined the balance sheet and income statement prepared by _____________________________, and that to the best of my knowledge and belief, it is true, correct, and the complete statement from the books and records of debtor.
SIGNED _____________________________ Officer of Owner of Debtor(s)
_____________________________
Title
Title
_____________________________
Date
Date
EXHIBIT 2 - Statement of Source and Application of Funds Period Covered
STATEMENT OF SOURCE AND APPLICATION OF FUNDS FOR THE PERIOD _____________________________
Funds Provided by:
Operations - Net income for the period __________
Add: Charges not affecting working capital (depreciation, amortization, etc.) __________
Less: Operating revenues not affecting working capital __________
Total find provided by Operation __________
Long term loans __________
Unrestricted cash donations __________
Other (identify) __________
Total funds provided __________
STATEMENT OF SOURCE AND APPLICATION OF FUNDS FOR THE PERIOD __________
Funds Applied to:
Retirement of long-term obligations (mortgages, notes, bonds, etc.) __________
Purchase of equipment __________
Purchase of land __________
Dividends to stockholders __________
Other (identify) __________
Total Funds Applied __________
Net Increase (Decrease) in Working Capital* __________
Working Capital* (end of period) (date) __________
Less: Working Capital* (beginning of period) (date) __________
Net Increase (Decrease) in Working Capital* __________
* Current Assets less Current Liabilities
EXHIBIT 3 - Cash Flow Statement Period Covered
CASH FLOW STATEMENT FOR THE PERIOD __________
Cash provided by:
Operations (net) (See Exhibit 4) __________
Cash donations (unrestricted) __________
Long-term borrowing __________
Investment earnings (cash dividends, interest) __________
Sale of long-term investments __________
Sale of equipment __________
Issuance of bonds __________
Decrease in current assets (other than Accounts Receivable, Prepaid Expenses, and Inventory) __________
Increase in current liabilities (other than Accounts Receivable, Prepaid Expense, and Inventory) __________
Others __________
Total Cash Provided __________
CASH FLOW STATEMENT FOR THE PERIOD
Cash applied to:
Purchase of equipment __________
Payment of long-term debt __________
Payment of bond redemption fund __________
Purchase of long-term investments __________
Payment of dividends__________
Purchase of land/building (purchase price less mortgage, capital stock and non-cash assets given toward purchase) __________
Increase in current assets (other than Accounts Receivable, Prepaid Expenses, and Inventory) __________
Decrease in current liabilities (other than Accounts Receivable, Prepaid Expense, and Inventory) __________
Others __________
Total Cash Applied __________
Increase (Decrease) in Cash__________
Cash at end of period (date) __________
Less: Cash at beginning of period (date) __________
Increase (Decrease) in Cash __________
EXHIBIT 4 - Projected Cash Flow Statement Cash From Operations (Schedule A) Period Covered
PROJECTED CASH FLOW CASH FROM OPERATIONS
Net Income (or Net Loss) __________
Increases: Depreciation expense __________
Loss from sale of equipment __________
Decrease in net Accounts Receivable __________
Decrease in Prepaid Expense __________
Decrease in Inventory __________
Increase in Accounts Payable __________
Increase in Prepaid Income __________
Others __________
Gross Cash from Operations __________
Decreases: Gain from sale of equipment __________
Increase in net Accounts Receivable __________
Increase in Prepaid Expense __________
Increase in Inventory __________
Decrease in Accounts Payable __________
Decrease in Prepaid Income __________
Others __________
Net Cash from Operations __________
