STATE OF NORTH CAROLINA STATE WIDE ACCOUNTS RECEIVABLE REPORTING FORM INSTRUCTIONS FISCAL YEAR ENDED JUNE 30, 2006 AGENCY NAME: CONTACT PERSON: CONTACT TITLE: CONTACT NUMBER: EMAIL ADDRESS: INSTRUCTIONS: 1. Complete all worksheets in this workbook. 2. Use glossary as reference for terms used on worksheets. 3. Financial information requested should be for fiscal year 2006. Other information requested should be as of the current date. 4. To report write-off, allowance, and aging information, a separate worksheet should be completed for each GASB fund type. For this purpose, insert additional worksheets into workbook as necessary . 5. Adjust cell height as necessary to display text entries. 6. Representation letter must be prepared on agency letterhead, signed and dated by agency chief executive officer and chief financial officer. The letter can be copied from the 'Rep Letter' worksheet and pasted into a Microsoft Word document. 7. Send electronically completed workbook with scanned representation letter to Cindy Salgado at email@example.com by no later than November 15, 2006. 8. Questions should be directed to Cindy Salgado at (919) 981-5484 or by email firstname.lastname@example.org. If unavailable, contact Amber Young at (919) 981-5481 or by email at email@example.com. COMPLETION OF THIS FORM BY NOVEMBER 15, 2006 IS REQUESTED. THANK YOU. STATE OF NORTH CAROLINA STATE WIDE ACCOUNTS RECEIVABLE REPORTING FORM BAD DEBT WRITE-OFF'S AND ALLOWANCE FOR DOUBTFUL ACCOUNTS FISCAL YEAR ENDED JUNE 30, 2006 GASB Fund Type: Agency No.: Agency Name: Preparer/Phone: SUBTOTAL INTER- NOTES TOTAL Write-Off Activity During Fiscal ACCOUNTS NOTES / LOANS INTERFUND OTHER CURRENT CURRENT RECEIVABLES - TAXES RECEIVABLE GOVERNMENTAL RECEIVABLE - RECEIVABLES 2006 RECEIVABLE RECEIVABLES RECEIVABLE RECEIVABLES RECEIVABLES RECEIVABLES NONCURRENT NONCURRENT WRITTEN OFF WRITTEN OFF RECEIVABLE WRITE-OFFS $0.00 $0.00 CONTRACTUAL ADJUSTMENTS $0.00 0.00 INDIGENT CARE WRITE-OFFS $0.00 0.00 TOTAL WRITE-OFFS FOR YEAR $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SUBTOTAL - INTER- NOTES TOTAL Allowance for Doubtful ACCOUNTS NOTES / LOANS INTERFUND OTHER CURRENT CURRENT RECEIVABLES - TAXES RECEIVABLE GOVERNMENTAL RECEIVABLE - RECEIVABLES Accounts at June 30, 2006 RECEIVABLE RECEIVABLES RECEIVABLE RECEIVABLES RECEIVABLES RECEIVABLES NONCURRENT NONCURRENT ALLOWANCE ALLOWANCE ALLOWANCE FOR DOUBTFUL ACCOUNTS: STUDENTS $0.00 $0.00 PATIENTS $0.00 0.00 TAX REVENUES $0.00 0.00 CONTRACTUAL ADJUSTMENTS $0.00 0.00 INDIGENT CARE WRITE-OFF'S $0.00 0.00 PLEDGES $0.00 0.00 CONTRIBUTIONS $0.00 0.00 OTHER BAD DEBTS $0.00 0.00 TOTAL ALLOWANCE FOR DOUBTFUL ACCOUNTS $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 STATE OF NORTH CAROLINA STATEWIDE ACCOUNTS RECEIVABLE REPORTING FORM ACCOUNTS RECEIVABLE AGING FISCAL YEAR ENDED JUNE 30, 2006 GASB Fund Type: Agency No: Agency Name: Preparer/Phone: __________________________PAST DUE______________________________ Accounts Receivable Balance at Fiscal DUE Type Year End 1-30 Days 31-60 Days 61-90 Days 91-120 Days Over 120 Days Taxes Receivable $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Accounts Receivable 0.00 Intergovernmental Receivables 0.00 Notes / Loans Receivable 0.00 Interfund Receivables 0.00 Other Current Receivables 0.00 Receivables Non- Current 0.00 Notes / Loans Receivable - Non- Current 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 STATE OF NORTH CAROLINA STATEWIDE ACCOUNTS RECEIVABLE REPORTING FORM RECEIVABLE COLLECTION COSTS FISCAL YEAR ENDED JUNE 30, 2006 Agency No: Agency Name: Preparer/Phone: Agency Collection Unit Type of Receivable Collection Cost FTE STATE OF NORTH CAROLINA STATEWIDE ACCOUNTS RECEIVABLE REPORTING FORM MANAGEMENT REPRESENTATION FISCAL YEAR ENDED JUNE 30, 2006 Agency Letterhead Current Date Mr. Robert L. Powell State Controller Raleigh, N.C. Dear Mr. Powell: We are providing this letter in connection with the preparation by the Office of the State Controller of a summary report on accounts receivable that is required by North Carolina General Statute 147-86.26. We confirm, to the best of our knowledge and belief, that for the (insert agency name): 1) Management is responsible for complying, and has complied, with requirements of Article 6B of Chapter 147 and Chapter 105A of the North Carolina General Statutes. 2) Management is responsible for establishing and maintaining, and has established and maintained, effective internal control over compliance with the requirements of Article 6B of Chapter 147 and Chapter 105A of the North Carolina General Statutes. 2) Information submitted to the Office of the State Controller for preparation of the aforementioned report is materially correct and verifiable to agency records. Signature of Chief Executive Officer__________________________ Date of Signature_______________________ Signature of Chief Financial Officer__________________________ Date of Signature_______________________ ve internal STATE OF NORTH CAROLINA STATEWIDE ACCOUNTS RECEIVABLE REPORTING FORM GLOSSARY OF TERMS FISCAL YEAR ENDED JUNE 30, 2006 Accounts Receivable Types: Taxes receivable, accounts receivable, intergovernmental receivables, other current receivables, notes/loans receivable, interfund receivables, receivables-noncurrent, and notes/loans receivable-noncurrent. Accounts Receivable: This account type includes amounts owed on open account from private persons, firms, or corporations for goods and services furnished by a State agency or institution during it’s normal course of business. Agency Collection Unit: The unit within the agency that performs the collection activity. Agency Name: The agency to whom the account receivable is owed. Aging: The number of days beyond the due date of the invoice. Allowance for Doubtful Accounts: The portion of receivables estimated not to be collectible. This information should be classified as either contractual adjustments, indigent care bad debts, or other bad debts. Bad Debt Write-Offs: All write-offs of bad debts other than those for contractual or indigent care reasons. Collection Cost: Includes direct and indirect cost related to the collection of receivables; for example, personnel, collection agency fees, supplies, etc. Contractual Adjustments: The differences between revenue at established rates and the amounts realizable from third-party payors under contractual agreements. These adjustments are made to customer, patient, business, or taxpayer accounts as the result of a contractual agreement to provide certain services or products at a previously negotiated price. The contractual adjustment is the difference between the value assigned by the State provider/supplier of the product or service, and the predetermined price as negotiated with a third-party payor (example: insurance company ). FTE: Full time equivalent. Indigent Care Write-offs: The differences between revenue at established rates and the amounts realizable from the financially responsible party for those receiving the State product or service. In this instance, the write-off is the result of the financially responsible party being unable to meet the financial obligations due to poverty or a lack of subsistence. Interfund Receivables: This account type consists of transfers due from fund types within an agency and transfers due from other agencies. Intergovernmental Receivables: This account includes receivables due from the federal government and local government units such as counties, cities and towns, school units, council on government agencies (COG'S), municipal finance agencies, etc. Notes / Loans Receivable: This account type includes student loans and other unconditional written promises, signed by makers, to pay sums certain in money on demand or at a fixed or determinable future time either to the bearer or to the order of a person designated therein. Notes / Loans Receivable - Noncurrent: This account type includes student loans and other unconditional written promises, signed by makers, to pay sums certain in money on demand or at a fixed or determinable future time either to the bearer or to the order of a person designated therein, which will not be collected until future fiscal periods.. Other Current Receivables: This account type includes all other current receivables not classified elsewhere. Receivables - Noncurrent: This account type includes earned revenues and other resources which will not be collected until future fiscal periods. Taxes Receivable: This account type consists of the uncollected portion of taxes the State has levied and are due.