Form MH-4466 "Licensure Application Addendum: Financial Statement Form" - Tennessee

What Is Form MH-4466?

This is a legal form that was released by the Tennessee Department of Mental Health & Substance Abuse Services - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the Tennessee Department of Mental Health & Substance Abuse Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MH-4466 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Mental Health & Substance Abuse Services.

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Download Form MH-4466 "Licensure Application Addendum: Financial Statement Form" - Tennessee

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OFFICE OF LICENSURE
LICENSURE APPLICATION ADDENDUM: FINANCIAL STATEMENT FORM
INSTRUCTIONS:
The applicant may choose to use this form or provide another written statement for showing financial solvency and
responsibility in making application for a license. The financial statement submitted must minimally address the assets, liabilities, and funds
available to the applicant for the operation of the applicant’s service and/or facility. The financial statement submitted must be signed, dated
and must accompany the application for license.
DATE of APPLICATION:
NAME of APPLICANT for LICENSE:
ASSETS: (Give the appraised or current, estimated worth of the following items:)
Real Estate/Land/Houses/Buildings
$_______________
Accounts Receivable
$ ______________
Furniture & Appliances
$_______________
Notes Receivable
$_______________
Motor Vehicles
$_______________
Prepaid/Donated Expns. $_______________
Other Movable Equipment
$_______________
Other Assets, List
$_______________
Other Fixed Equipment
$_______________
___________________ $_______________
Cash in Hand/Bank Accts.
$_______________
___________________ $_______________
Savings or Investments
$_______________
___________________ $ _______________
TOTAL AMOUNT OF ASSETS:
$_______________
LIABILITIES: (List the total amounts owed on the following)
Mortgages
$ ______________
Bank/Creditor Loans
$ ______________
Other Property Liens
$ ______________
Other/Long-term Loans $ ______________
Auto/Vehicle Loans
$ ______________
___________________ $ ______________
Personal Loans
$ ______________
___________________ $ ______________
TOTAL AMOUNT OF LIABILITIES:
$ ______________
OPERATING EXPENSES: (List the monthly amount of expenses of the following)
Employees’ Salaries
$ _____________
Home/Prop.Insurance $ ______________
Proprietor’s Salary
$ ______________
Vehicle Insurance
$ ______________
Payroll Taxes
$ ______________
Other Insurance
$ ______________
Utilities
$ ______________
__________________ $ ______________
Rent
$ ______________
___________________ $ ______________
Page 1 of 2
OFFICE OF LICENSURE
LICENSURE APPLICATION ADDENDUM: FINANCIAL STATEMENT FORM
INSTRUCTIONS:
The applicant may choose to use this form or provide another written statement for showing financial solvency and
responsibility in making application for a license. The financial statement submitted must minimally address the assets, liabilities, and funds
available to the applicant for the operation of the applicant’s service and/or facility. The financial statement submitted must be signed, dated
and must accompany the application for license.
DATE of APPLICATION:
NAME of APPLICANT for LICENSE:
ASSETS: (Give the appraised or current, estimated worth of the following items:)
Real Estate/Land/Houses/Buildings
$_______________
Accounts Receivable
$ ______________
Furniture & Appliances
$_______________
Notes Receivable
$_______________
Motor Vehicles
$_______________
Prepaid/Donated Expns. $_______________
Other Movable Equipment
$_______________
Other Assets, List
$_______________
Other Fixed Equipment
$_______________
___________________ $_______________
Cash in Hand/Bank Accts.
$_______________
___________________ $_______________
Savings or Investments
$_______________
___________________ $ _______________
TOTAL AMOUNT OF ASSETS:
$_______________
LIABILITIES: (List the total amounts owed on the following)
Mortgages
$ ______________
Bank/Creditor Loans
$ ______________
Other Property Liens
$ ______________
Other/Long-term Loans $ ______________
Auto/Vehicle Loans
$ ______________
___________________ $ ______________
Personal Loans
$ ______________
___________________ $ ______________
TOTAL AMOUNT OF LIABILITIES:
$ ______________
OPERATING EXPENSES: (List the monthly amount of expenses of the following)
Employees’ Salaries
$ _____________
Home/Prop.Insurance $ ______________
Proprietor’s Salary
$ ______________
Vehicle Insurance
$ ______________
Payroll Taxes
$ ______________
Other Insurance
$ ______________
Utilities
$ ______________
__________________ $ ______________
Rent
$ ______________
___________________ $ ______________
Page 1 of 2
Food Supplies
$ ______________
___________________ $ ______________
Non-Food Supplies
$ _______________
Contracted Professional/Other Expenses $ _______________
_________________________________ $ _______________
_________________________________ $ _______________
TOTAL MONTHLY OPERATING EXPENSES
$_______________
INCOME: (List all sources of monthly income available for operation of the facility and/or services)
Income from Client-paid fees
$ _______________
Income/Other Sources
$ _______________
Income from Client fees paid by
Third Parties
$ _______________
__________________
$ _______________
Interest Income
$ _______________
__________________
$ _______________
TOTAL MONTHLY INCOME
$ _______________
OTHER: Use this space to provide any other information you believe would be helpful in determining your financial
solvency and responsibility:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
CERTIFICATION: The undersigned hereby certifies that this information is true, correct and complete to the best of
his/her knowledge.
NAME OF LICENSEE
DATE
TITLE
MH-4466 (Rev. 08-12)
RDA-2827
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