Form E-Qtr - Ahcccs Contractor Quarterly Premium Tax Report
Download a blank fillable Form E-Qtr - Ahcccs Contractor Quarterly Premium Tax Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form E-Qtr - Ahcccs Contractor Quarterly Premium Tax Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1DEPARTMENT OF INSURANCE
AHCCCS CONTRACTOR
QUARTERLY PREMIUM TAX REPORT
STATE OF ARIZONA
Reset
Financial Affairs Division- Tax Unit
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
Phone: (602) 364-3998
Fax: (602) 364-3989
AHCCCS Contractor’s Complete Name
Federal I.D. Number
Type Preparer’s Name and Title
Toll free or collect phone number
Fax number
E-Mail Address
INSTRUCTIONS AND ESTIMATED TAX COMPUTATION
An AHCCCS Contractor is required to file this report and pay its estimated premium tax pursuant to A.R.S. §§ 36-2905 and 36-2944.01 on or before
each “due date” shown in 1, below. See Form E-QTR.INSTRUCTION for further assistance with quarterly reporting and payment requirements.
1.
WRITE AN “X” IN THE BOX THAT CORRESPONDS TO THE QUARTER FOR WHICH THIS REPORT IS BEING FILED
OFFICE USE ONLY
SELECT
DUE DATE FOR TAX
PERIOD
PAY
ONE
FOR CONTRACTOR CAPITATION IN:
REPORT AND PAYMENT
CODE
CODE
TAX
PAYMENT
QUARTER 1: January 1 through March 31
March 15
1
74
DUE DATE
QUARTER 2: April 1 through June 30
June 15
4
76
TABLE
QUARTER 3: July 1 through September 30
September 15
19
78
QUARTER 4: October 1 through December 31
December 15
20
79
2.
ENTER THE AHCCCS PLAN I.D. NUMBER AND ESTIMATED AMOUNT OF TOTAL CAPITATION, including reinsurance and any other
reimbursement paid to the Contractor by the Arizona Health Care Cost Containment System, for this quarter for each plan type.
AHCCCS Plan Types
Enter Plan I.D. Number
Enter Estimated Amounts
Acute Care
$
AC
Ventilator Dependent
$
VD
Elderly & Physically Disabled
$
EPD
LINE 2 TOTAL
$
QT
0.00
3..... PREMIUM TAX DUE: Enter 2% (0.02) of LINE 2 TOTAL amount, above ..............................................................$
«
0.00
4.
CIVIL PENALTY AND INTEREST COMPUTATION: A payment by check must be mailed, or an ACH payment must post to the Department’s
ACH account, on or before the Due Date.
If PREMIUM TAX DUE on line 3 is paid in full on or before the due date shown in the Tax Payment Due Date Table (line 1) for the selected
quarter, enter 0 (Zero) on line 4c
If PREMIUM TAX DUE on line 3 is paid after the due date shown in the Tax Payment Due Date Table (line 1) for the selected quarter,
complete lines 4a, b and c
4a. Late Payment Penalty: Enter 5% (0.05) of the amount on line 3
or $25.00, whichever is greater............................................................... $
4b. Interest: Multiply the amount on line 3 times 1% (0.01) for
each full or partial month that the payment is late.................................... $
4c. Total Penalty and Interest Due: Add lines 4a and 4b....................................................................................$
« [
0.00
26]
5.
PRIOR QUARTER PREMIUM TAX ADJUSTMENT from line 3 of Form E-QTR.ADJUSTMENT
.............$
(attached)
0.00
6.
TOTAL PAYMENT DUE: Sum of lines 3, 4c and 5 .................................................................................................$
«
PAYMENT OPTIONS: CHECK ONLY ONE BOX AND PROVIDE INFORMATION FOR THE SELECTED PAYMENT OPTION
Check #
payable to the Arizona Department of Insurance for the amount shown on line 6 is enclosed.
Payment in the amount shown on line 6 sent via ACH delivery on
_____________________ in accordance with Form E-ACH.INSTRUCTION.
(date)
Mail this Report, with your check if payment will not be sent via ACH delivery, to the address shown at the top of this form.
E-QTR (12/05)
P
1
1
AGE
OF
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal