APPLICATION FOR LIFE CARE PROVIDER PERMIT
Form E652 (v 20180619) Page 4 of 5
13. If construction or purchase of the facility has not yet been completed, a statement of the anticipated source and
application of the monies to be used in such purchase or construction, including all of the following:
A. An estimate of the cost of purchasing or constructing and equipping the facility including such related costs as
financing expense, legal expense, land costs, occupancy development costs and all other similar costs that the
provider expects to incur or become obligated for before the commencement of operations.
B. An estimate of the total entrance fees to be received from residents on completion of occupancy.
C. A description of any mortgage loan or other long-term financing intended to be used for the financing of the facility,
including the anticipated terms and costs of such financing.
D. An estimate of any funds which are anticipated to be necessary to fund start-up losses and to assure full
performance of the obligations of the Provider pursuant to life care contracts including any reserve fund escrow
required by the Director pursuant to A.R.S. § 20-1806.
14. Certified financial statements of the Provider, promoter and manager as of a date not more than ninety days before the
date the permit Application is filed, that shall include a balance sheet and the related statements of income, retained
earnings or equity and changes in financial position for the three most recent fiscal years or any shorter period of time
as the Provider, promoter or manager has been existence. Each of these statements shall be prepared in accordance
with generally accepted accounting principles and reported on by a certified public accountant in accordance with
generally accepted auditing standards. If the fiscal year ended more than ninety days before the date of filing, the
Provider shall include an income statement, that need not be certified, covering the period between the date the fiscal
year ended and a date not more than ninety days before the date the Application is filed. [Attach as exhibits].
15. A feasibility study that shall include a financial forecast of the life care facility estimating the most probable financial
position, results of operations and changes in financial position for the immediately succeeding five year period. The
feasibility study must set forth the actuarial assumptions for determining that the project has sufficient revenues and
funds, including reserves, for the project to continue as a viable operating concern. The study must include all of the
following:
A. Beginning cash balance, and in the event that operation of the facility has not yet commenced, the beginning cash
balance shall be consistent with the statement of anticipated source and application of funds described in Item 13.
B. Anticipated earning on cash reserves.
C. Estimates of net receipts from entrance fees, other than entrance fees included in the statement of source and
application of funds required under Item 13, less estimated entrance fee refunds and a description of the actuarial
basis and method of calculation for the projection of entrance fee receipts.
D. An estimate of gifts or bequests if any are to be relied on to meet operating expenses.
E. A projection of estimated income from fees and charges other than entrance fees, showing individual rates presently
anticipated to be charged, including a description of the assumptions used for calculating the effect on the income
of the facility of subsidized health services to be provided pursuant to the life care contracts.
F. A projection of estimated operating expenses of the facility and for providing services in contract holders’ private
residences, including a description of the assumptions used in calculating the expenses, and separate allowances
for the replacement of equipment and furnishings and anticipated major structural repairs or additions.
G. An estimate of annual payments of principal and interest required by any mortgage loan or other long-term
financing.
[Attach as exhibit].
