voluntary, but is required to obtain a
of Need. If
not completed, a
of Need will not be issued.
Department of Health & Human Services is an equal opportunity
employer, services and programs provider.
Name of Applicant
be exactly the same as Section 2 filed on Letter of Intent.)
Licensed Name of Facility or Current Name of Facility
means an expenditure for a single project, including cost of
construction, engineering, and equipment that under generally
accepted accounting principles is not properly chargeable as an
expense of operation. Capital expenditure includes a lease or
comparable arrangement by or on behalf of a health facility to obtain
a health facility, licensed part of a health facility (i.e., a
licensed Hospital Long-Term Care Unit or licensed Psychiatric Unit),
or equipment for a health facility, if the actual purchase of a
health facility, licensed part of a health facility, or equipment for
a health facility would have been considered a capital expenditure
under this part. Capital expenditure includes the cost of studies,
surveys, designs, plans, working drawings, specifications, and other
activities essential to the acquisition, improvement, expansion,
addition, conversion, modernization, new construction, or replacement
of physical plant and equipment.
NOTIFICATION TO APPLICANT -
lease(s) will be valid for the term of the lease(s) only (including
renewable options) and the applicant will be required to file another
Certificate of Need to renew a lease(s.) In the case of Capital
equipment lease(s) in which the applicant purchases the equipment,
the Certificate of Need is valid until the applicant replaces the
equipment. However, if the applicant does not purchase the equipment
at the end of the original lease(s) and instead renews the lease(s),
a new Certificate of Need will be required.
FOR COMPLETION OF PROJECTS COSTS
each line item as shown on the form. For those items not applicable
enter 0 or N/A.
estimated costs including the effects of inflation must be based on
the projected midpoint of construction.
New Construction and Renovation & Remodeling must be broken
down into clinical and non-clinical costs and recorded under the
appropriate line on page 3 of this form. Please list the area
covered by the new construction and renovation under the appropriate
line on page 3 of this form.
means equipment that is affixed to and constitutes a structural
component of a health facility, including, but not limited to,
mechanical or electrical systems, elevators, generators, pumps,
boilers, and refrigeration equipment. These costs must be included
in new construction and/or remodeling/renovation costs. Those items
determined not to be part of new construction or renovation will be
considered depreciable fixed equipment and must be identified in the
line for Fixed Equipment on Page 3 of this form.
Capital and Operating Leases must
listed as an asset and liability based on the definition of Capital
Expenditure provided under CON Law. The lease cost is calculated by
taking the annual lease payment multiplied by the number of years of
the lease including any renewal options. Use the base rental rate,
ignoring any additional rent increases.
you are unable to provide a detailed breakdown of financing and
related debt issue costs, then provide an estimate as a percentage of
total loan amount.
must equal the TotalSources
8. Provide assumptions and
rationale for each line item. In absence of detailed assumptions,
the analysts reviewing the project will make their own assumptions
based on data provided in this and other sections of the application.
data on project costs for computation errors and for conflict with
data reported on other forms. For example:
Sources of Funds
b. During preparation of a
Certificate of Need application, figures and assumptions are
sometimes revised. If you have made such revisions, have these
changes been entered on all affected forms?
Attach a copy of audited financial statements. If audited financial
statements are not available, provide unaudited current financial
statements including a balance sheet, income statement, statement of
cash flows and any notes to accompany the financial statements. New
entities must provide a current balance sheet, a projected income
statement for the first year of operations, a projected statement of
cash flows for the first year of operations, and any notes to
accompany the financial statements.
For all projects involving initiation, replacement or upgrade of
cardiac catheterization laboratories, CT scanners, Lithotripsy Units,
MRI scanners, MRT units, and PET scanners, attach a copy of a vendor
signed and dated vendor quotation that was issued within the past six
Whole Dollars Only)
Construction - Clinical (
Construction – Non Clinical (
and Remodeling - Clinical (
and Remodeling – Non Clinical (