Montana Department Of Revenue Hospital Facility Utilization Fee Form

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MONTANA

Clear Form

HUF

Rev 01 16

Hospital Facility Utilization Fee

15-66-101, MCA

Return and Instructions

Line 7:

Enter total number of inpatient bed days for the period indicated on line 3.

Line 8:

Enter hospital facility utilization fee due. Multiply line 7 by the rate of $50.00.

Line 9:

Enter amount of interest and penalty if applicable. The late payment penalty accrues at 1.2% a month, not to

exceed 12% of the tax due. In addition, a late filing penalty of $50 or the amount of the tax due, whichever

is less, also applies if the return is filed late. If payment is delinquent, interest will apply at 12% per year,

calculated daily, from the original due date of this report until paid.

Line 10: Enter total amount due (sum of lines 8 and 9).

Line 11: Enter amount paid with this return. This is the amount on line 10.

If you have questions, please call us toll free at (866) 859-2254 (in Helena, 444-6900).

Make check payable to the Department of Revenue. Mail this return and payment to:

Department of Revenue, PO Box 5835, Helena, MT 59604-5835

--------------------------------------------------------------------------------- Cut on this line --------------------------------------------------------------------------------

Montana Department of Revenue

Hospital Facility Utilization Fee (HUF)

1. FEIN

2. Account ID

3. Period Ending

4. If this is an amended

Above space is for department use only

return, check here.

January 31, 20 __ __

7. Total number of inpatient bed days for the

5. If you are no longer in business and want your account cancelled,

year