Nonpublic Postsecondary Education Commission
Exhibit K
Financial Statement
Initial Application
Renewal Application
Name of Institution
Address
Ending Date for Institution's Fiscal Year
Date Financial Statement Submitted to NPEC
Name of Person Completing Financial Statement
Each institution must submit a financial statement with its
application for, or renewal of, a Certificate of Authorization,
using the Exhibit K Financial Statement form (see instructions
for exceptions). The financial statement is to cover the
institution's twelve-month fiscal year. Accounts and financial
records of the institution must be established separately from
the personal finances of the owners. The Nonpublic
Postsecondary Education Commission may also require an
independent compilation, review, or audit by a certified public
accountant if the institution is a branch or subsidiary of
a corporation with other campuses, programs, or
business activities, an annual corporate financial
statement is to be submitted in addition to the Exhibit K
form. Further information is provided in "Instructions for
Exhibit K Financial Statement."
Revised April 2015
1
1. INCOME AND EXPENSE STATEMENT
For the Fiscal Year Beginning
20
20
and Ending
INCOME:
1. Gross Tuition Received (Before refunds)
$
2. Gross Application Fees Received (Before refunds)
3. GrossTuition Plus Application Fees
(Total of lines 1 through 2)
4. Less: Refunds of Tuition or Fees on Lines 1 and 2 (Enter Minus Sign)
5. Net Tuition and Fees (subtract line 4 from line 3)
6. Other Fees (List all other fees which are charged separately from tuition.):
6a.
6b.
6c.
7. Other Charges:
7a.
7b.
8. Dormitory Income
9. Bookstore Income
10. Interest/Dividend Income
11. Other Income:
11a.
11b.
12. TOTAL INCOME (Total of lines 5 through 11b)
OPERATING EXPENSES: (All expenses must be preceeded by a minus sign to calculate)
13. Instructional Salaries and Benefits:
Number of Instructional Staff: Full-Time
Part-Time
13a. Instructional Staff Salaries
13b. Employer-Paid Health Insurance for Instructional Staff
13c. Employer-Paid Retirement for Instructional Staff
13d. Other Employer-Paid Benefits for Instructors (Describe in attached note.)
__________________
14. Administrative Salaries and Benefits
15. Officer Salaries and Benefits*
16. Agent Salaries and Benefits
17. Other Salaries/Wages and Benefits (Personnel not Included on lines 13-16)
* In an attached note, list each officer receiving a salary, identify the amount of the salary, and the amount paid by the
institution for benefits for each officer.
Revised April 2015
2
OPERATING EXPENSES (Continued):
18. Textbook Expenses
$
19. Instructional Expenses (Instructional publications, materials, supplies, etc.)
...
20. Library Expenses Other than Salaries and Benefits
21. Student Recruitment Expenses Other Than Salaries and Benefits
(Advertising costs. Promotional literature, etc.)
22. Depreciation Of Facilities and/or Equipment
23. Occupancy Expenses:
23a. Rent
23b. Mortgage Interest
23c. Utilities
23d. Other Occupancy Expenses
...
24. Administrative Expenses*
25. Student Services Expenses*
26. Dormitory Expenses
27. Bookstore Expenses
28. Interest Expenses (Except mortgage interest included on line 23b above)
...
29. Other Operating Expenses:
29a.
29b.
30. TOTAL EXPENSES (Total of lines 13a through 29b)
31. NET INCOME BEFORE INCOME TAXES (Subtract line 30 from line 12)**
32. Less: Federal and State Income Taxes (if applicable)
33. TOTAL INCOME AFTER TAXES (Subtract line 32 from line 31)
* In an attached note, provide a list of the major categories of expense items included in the amounts reported here.
Show the expense amount for each category listed.
** If line 31 is a negative number, see Instructions for required statement
*****************************************************************
II. RETAINED EARNINGS HISTORY
Enter the requested information for the three immediate past fiscal years (prior to the fiscal Year Identified on page 1):
, 20
Fiscal Year Ending:
A. Beginning Balance
B. Add: Earnings for Year
C. Minus: Withdrawals and Dividends(-)
D. Other Retained Earnings Charges(-)
E. ENDING BALANCE (Net total of
A through D above)
Revised April 2015
$
, 20
$
, 20
$
3
III. BALANCE SHEET
as of
A.
, 20
ASSETS
CURRENT ASSETS:
34. Cash on Hand In Banks - Unrestricted
35. Cash - Restricted
36. Accounts Receivable, Students - Net (Current)
37. Accounts Receivable, Students - Net (Old) (Note: List only those
overdue amounts which have not been written off as bad debt)....
38. Accounts Receivable, Other - Net:
38a.
38b.
39. Notes Receivable*
40. Inventory - Books and Supplies
41. Temporary Investments*
42. Other Current Assets:
42a.
42b.
42c.
43. TOTAL CURRENT ASSETS (Total of lines 34 through 42c)
FIXED ASSETS:
44. Buildings
45. Less: Accumulated Depreciation - Buildings**
46. Furniture and Equipment
47. Less: Accumulated Depreciation - Furniture and Equipment**
48. Leasehold Improvements
49. Less: Accumulated Amortization of Leasehold Improvements
50. Library
51. Less: Accumulated Depreciation - Library**
52. Vehicles Owned by the Institution
53. Less: Accumulated Depreciation - Vehicles**
54. Land
* In an attached note provide lists of assets and amounts reported for these items. Show the amount for each item
listed.
* * List depreciation methods on page 6, lines 94-98.
Revised April 2015
4
FIXED ASSETS (Continued)
55. Other Fixed Assets:
55a.
$
55b.
56. Less: Accumulated Depreciation - Other Fixed Assets*
57. TOTAL FIXED ASSETS (Net total of lines 44 through 56)
OTHER ASSETS:
58. Deposits
59. Prepaid Expenses
60. Revolving Book Account
61. Perkins, NDSL, or Other Loan Program Matching Funds (Net)
62. Other Assets:
62a.
62b.
63. TOTAL OTHER ASSETS (Total of lines 58 through 62b)
64. TOTAL ASSETS (Total of lines 43, 57, and 63)
*****************************************************************
B.
LIABILITIES AND STOCKHOLDER'S / OWNER'S EQUITY
LIABILITIES
CURRENT LIABILITIES:
65. Accounts Payable - Trade
66. Notes Payable - Equipment*
67. Notes Payable - Other*
68. Tuition Refunds Payable
69. Current Portion - Long Term Debt
70. Payroll Taxes Payable
71. Income Taxes Payable
72. Accrued Salaries and Wages
73. Unearned Tuition
74. Unearned Dormitory Fees
* List depreciation method on page 6.
* * In an attached note, provide lists of notes payable which are included in the amounts reported here. Show the principal
balance, term, and regular payment for each Item listed.
Revised April 2015
5
CURRENT LIABILITIES (Continued)
75. Other Unearned Revenue:
$
76. Other Current Liabilities:
76a.
76b.
76c.
77. TOTAL CURRENT LIABILITIES (total of lines 65 through 76c)
LONG-TERM LIABILITIES:
78. Notes or Bonds Payable*
79. Mortgages Payable*
80. Other Long-Term Liabilities:*
80 a.
80 b.
81. TOTAL LONG-TERM LIABILITIES (Total of lines 78 through 80 b)
82. TOTAL LIABILITIES (total of lines 77 and 81)
STOCKHOLDER'S / OWNER'S EQUITY:
83. Preferred Stock
84. Common Stock or Owner's Investment
85. Other Equity
Retained Earnings:
86. Beginning Balance
87. Add: Earnings for Year (From line 33 on page 2)
88. Deduct: Withdrawals and Dividends**
89. Less Other Retained Earnings Charges**
90. ENDING BALANCE (Net total of lines 86 through 89)
91. TOTAL STOCKHOLDER'S / OWNER'S EQUITY (Total of lines 83, 84, 85, and 90)
92. TOTAL LIABILITIES AND EQUITY (Total lines 82 & 91; must equal line 64 page 4)
* In an attached note, provide lists of notes payable which are included in the amounts reported here. Show the principal
balance, term, and regular payment for each Item listed.
* * In an attached note, provide descriptions of withdrawals, dividends, and retained earnings charges.
Revised April 2015
6
IV. DISCLOSURES
METHODS USED TO DETERMINE:
93. Inventory - Books and Supplies
94. Depreciation - Buildings
95. Depreciation - Furniture and Equipment
96. Depreciation - Library
97. Depreciation - Vehicles
98. Depreciation - Other-Fixed Assets
99. Unearned Tuition
100. Unearned Dormitory
Fees
101. BASIS FOR FINANCIAL
ACCOUNTING:
102. STATUS OF INSTITUTION:
Non-Profit
Cash
For-Profit: Individual Owner
Accrual
For-Profit:
For-Profit: "C" Corporation
For-Profit: "S" Corporation
Partnership
103. STOCKHOLDERS
List stockholders, if any, who hold at least 10 percent of issued and outstanding shares:
OTHER DISCLOSURES (include any other pertinent information In attached supplemental notes.)
104. Has the institution, its parent company (if any), or any owner ever entered into bankruptcy proceedings?
Yes
No
If yes, state the entity and/or individual(s), type of proceeding and date(s) in an attached note.
105. Does the institution participate In any federal, state, or other student loan or grant programs?
Yes
No
If yes, list the loan or grant program(s) in an attached note, and indicate the institution's
default rate for each of the most recent three years.
106. Was the institution ever terminated from participation in a federal, state, or other student loan or grant program?
Yes
No
If yes, indicate in an attached note the loan or grant program(s), the date(s) of termination
from participation, and the reason(s) for the termination.
107. Is the Institution the defendant in any civil action, or has it been held liable as a result of recent litigation for
monetary damages to students, former students, or other plaintiffs?
Yes
No
If yes, describe the litigation, provide date(s), and indicate monetary judgments or
settlements. Identify and describe any insurance held by the institution to cover such liability.
STATEMENT OF AFFIRMATION
I hereby affirm that I am an officer, partner, or owner of the above-named institution, that this financial statement has been
prepared from the original records of the institution, and that financial records of the institution are maintained according
to accepted accounting principles. I attest that all information provided herein is accurate to the best of my knowledge.
Name
Title
Signature
Date
Revised April 2015