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2012 ANNUAL STATEMENT
Continuing Care Retirement Community - General Filing Instructions

This annual statement is for use by Continuing Care Retirement Communities authorized pursuant to Article 46 of the Public Health Law.

Each Continuing Care Retirement Community is required to submit a paper version of page 1 of the Jurat with original signatures of the officers and notary. Photocopies of signatures and/or notarization will NOT be accepted.

This Web site also provides specific instructions for filing the New York CONTINUING CARE RETIREMENT COMMUNITY Annual Statement with the Department of Financial Services and Department of Health. A copy of the New York CONTINUING CARE RETIREMENT COMMUNITY Annual Statement and Instructions are available as indicated below.

The Department of Financial Services recommends that each Continuing Care Retirement Community download the forms packet and return the annual statement material electronically (e.g., via email or on a compact disc). A Continuing Care Retirement Community may contact the Department of Financial Services as indicated below and request a copy of the annual statement material.

Continuing Care Retirement Community - Specific Filing Information

The Continuing Care Retirement Community Filing INSTRUCTIONS AND FORMS PACKET is a self extracting zipped file; after downloading file, run EXE to obtain the following files. The Instructions are in PDF format. The Jurat and Interrogatories are Microsoft Office Word 2003 files. The Statement Blank is a Microsoft Office Excel 2003 file. The instructions and forms are set up to use standard 8.5" x 11" paper.

FORMS included for Download and/or Print:

To view full instructions for unzipping compressed files, please select this link.

DUE DATE & MAILING

The annual statement is required to be filed within four months of the close of the community's fiscal year, unless an extension has been granted by the Department of Health. (Any request for extension should be addressed to the Department of Health, with a copy to the Department of Financial Services, and be sent to the email addresses or mailing addresses indicated below. All extension requests must clearly state the reason for the extension, whether or not the audited financial statement will be ready to be submitted by the required filing date, and the extension date being requested.)

It is recommended that an electronic copy of the jurat file, blank file, interrogatories file, audited financial statement, and any supporting material, be submitted to the Department of Financial Services (email Gary Teitel: Gary.Teitel@dfs.ny.gov) and to the Department of Health (email Michael Heeran: meh18@health.state.ny.us).

Electronic material on a compact disc is to be sent to the addresses indicated below.

Page 1 of the Jurat with ORIGINAL signatures, and any material that was not submitted electronically, are to be sent to the addresses indicated below. Two paper copies are to be submitted to the Department of Financial Services and one paper copy to the Department of Health. One Jurat with ORIGINAL signatures must be sent to the Department of Financial Services.

New York State Department of Financial Services
Health Bureau
One State Street
Attention: Gary Teitel, Assistant Chief Actuary
New York, New York 10004

OHSM, New York State Department of Health
Nursing Home Licensure and Certification
Attention: Michael E. Heeran
875 Central Avenue
Albany, New York 12206

PROBLEMS AND QUESTIONS:
If you need help filling out your forms, contact: Health Bureau, Mr. Gary Teitel (212) 480-7709, mailto: Gary.Teitel@dfs.ny.gov

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