2016 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 and the Certificate of Compliance 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 compressed zipped file; after downloading, unzip to obtain the following files. The Instructions are in PDF format and you will need the Adobe Acrobat Reader to view or print this file. The Jurat and Interrogatories are Microsoft Office Word 2013 files. The Statement Blank is a Microsoft Office Excel 2013 file. The instructions and forms are set up to use standard 8.5" x 11" paper.

FORMS included for Download and/or Print:

• JURAT (PAGES 1 AND 2 OF THE STATEMENT) 2016
• STATEMENT BLANK 2016
• INTERROGATORIES 2016
• CERTIFICATE OF COMPLIANCE 2016
• INSTRUCTIONS FOR COMPLETING THE ANNUAL STATEMENT MATERIAL 2016

DUE DATE & MAILING

The annual statement is required to be filed within four months of the close of the community's fiscal year (all statement filings are expected to be made timely).

It is recommended that an electronic copy of the jurat file, blank file, certificate of compliance, interrogatories file, audited financial statement, and any supporting material, be submitted to the Department of Financial Services (email Warren Youngs: Warren.Youngs@dfs.ny.gov; and Mark Brandes, Mark.Brandes@dfs.ny.gov; and Andre Blackman, Andre.Blackman@dfs.ny.gov) and to the Department of Health (email Susan Root: Susan.Root@health.ny.gov).

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

Page 1 of the Jurat and the Certificate of Compliance 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 and Certificate of Compliance with ORIGINAL signatures must be sent to the Department of Financial Services.

PROBLEMS AND QUESTIONS:
If you need help filling out your forms, contact: Health Bureau, Mr. Warren Youngs (212) 480-3883 or Mr. Andre Blackman (212) 709-7619, mailto: Warren.Youngs@dfs.ny.gov and Andre.Blackman@dfs.ny.gov.