Form Hcp-R - Maine Revenue Sevices Health Care Provider Tax Reconciliation Return

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HCP
Maine Revenue Sevices
Health Care Provider Tax
00
Reconciliation Return
*0814500*
Fiscal Year
Registration No.
Due Date
1. Entity Information
Use this area only to report changes in your business
2. OUT OF BUSINESS?
Check here
, return permit to Bureau and
complete information at right. Date closed:
3. OWNERSHIP CHANGE?
If you have changed ownership, indicate the date
when this occured here
and check the type of change below.
Partner added or dropped
Incorporated
Other (explain on reverse)
Sold to
4. NAME CHANGE?
Attach explanation to this return.
ADDRESS CHANGE? If your address above is incorrect, please make the appropriate changes to the preprinted address.
See reverse side for instructions
1. Revenue thru 12/31/07
1.
,
,
.
,
,
2. Revenue for 1/1/08 thru FY end
2.
.
3. Health Care Provider Tax
3.
,
,
(see reverse side for instructions)
.
4. Less: Monthly estimated payments made
4.
,
,
.
,
,
.
5. Additional Amount Due
5.
(Line 3 less line 4. Use line 6 if this is a credit amount.)
,
,
.
6. Credit Due
6.
(If line 3 minus line 4 is a credit amount, enter the amount to the right.)
If you wish a refund rather than a carry forward to the next period, check here
Mail To:
Maine Revenue Service
P.O. Box 9119
Augusta, ME 04332-9119
Print Name
Phone #
Date
Signature and Title
HCP-R Revised 07/08

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