Form Hcp-64 - Outpatient Health Care Facility Surcharge Return printable pdf download

Form Hcp-64 - Outpatient Health Care Facility Surcharge Return

State of Rhode Island and Providence Plantations

Department of Revenue - Division of Taxation

One Capitol Hill

Providence, RI 02908-5811

Outpatient Health Care Facility Surcharge Return

For the Month of: ____________________

Due Date: 25th day of the following month

Federal Identification Number: ______________________________________________

Name: __________________________________________________________________

Address: ________________________________________________________________

City: _________________________________ State: ________ Zip: ______________

Calculation of amounts due:

1. Net Patient Services Revenue Received

1. ________________

2. Outpatient Health Care Facility Surcharge (

) 2. ________________

Line 1 multiplied by 2.0%

3. Interest ( As provided in R.I.G.L. 44-1-7 )

3. ________________

4. Penalty ( 10% )

4. ________________

5. TOTAL DUE ( Add lines 2, 3 and 4 )

5. _______________

__________ ________________________________________ ___________________

Date

Signature

Title

Telephone Number: ___________________________________

(Under penalties of perjury, I declare that I have examined this return and to the best of my knowledge it is

true, correct and complete.)

Instructions:

Line 1: Net Patient Services Revenue Received means all monies and other consideration received in that

month for patient care services

Interest rate is 18% per annum. Interest is calculated from the due date of the return to date of remittance.

Penalty of 10% of the assessment is payable if remittance is not made by the due date.

After November 1, 2007, payments shall be made by Electronic Funds Transfer (EFT).

Questions regarding EFT transfers may be directed to (401) 222-6282.

Form HCP-64

Form Hcp-64 - Outpatient Health Care Facility Surcharge Return