Form Wv/hcp-3a - West Virginia Annual Return Of Broad Based Health Care Related Taxes 2008 Page 2
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2
32008
WV ANNUAL RETURN OF BROAD
FEIN
BASED HEALTH CARE RELATED TAXES
PERIOD
PERIOD
BEGINNING
ENDING
MM
DD
YYYY
MM
DD
YYYY
SCHEDULE A COMPUTATION OF TAX
LINE
COL 1
COL 4
TAXABLE
COL2
COL 3
COL 5
COL 6
CODE
TOTAL GROSS
TAXABLE GROSS
SERVICE
BAD DEBT
CONTRACTUAL
RATE
TAX DUE
PROCEEDS
PROCEEDS
ALLOWANCES
COL 4 X COL 5
(COL 1 - COL 2 & 3)
Ambulatory
Surgical
Independent
Lab/X-Ray
Inpatient
Hospital
Intermediate Care
Facility/MR
Outpatient
Hospital
SCHEDULE A TOTAL TAX DUE (ADD COL 6 FOR ALL TAXABLE SERVICES) ENTER HERE AND ON SCHEDULE E LINE 1
PERIOD
PERIOD
ENDING
BEGINNING
SCHEDULE B COMPUTATION OF TAX
DD
MM
DD
MM
YYYY
YYYY
COL 4
COL 6
COL 1
COL2
COL 3
COL 5
LINE
TAXABLE
TAXABLE GROSS
TAX DUE
TOTAL GROSS
BAD DEBT
CONTRACTUAL
RATE
CODE
SERVICE
PROCEEDS
COL 4 X COL 5
PROCEEDS
ALLOWANCES
(COL 1 - COL 2 & 3)
Chiropractic
Dental
Emergency
Ambulance
Nursing
Optician
Optometry
Physician
Podiatry
Psychological
Therapists
SCHEDULE B TOTAL TAX DUE (ADD COL 6 FOR ALL TAXABLE SERVICES) ENTER HERE AND ON SCHEDULE 3 LINE 2
SCHEDULE A.
Report revenue for the full taxable year.
Insert appropriate Line Code and tax rate for reportable business activity.
Accrual Basis taxpayers may reduce their Column 1 Total Gross Proceeds by Column 2 Bad Debt and Column 3 Contractual
Allowance deductions to the extent that they were included in gross receipts upon which the tax imposed was paid.
Cash Basis taxpayers may not claim Column 2 Bad Debt and Column 3 Contractual Allowance deductions
SCHEDULE B.
Report revenue from the beginning of your taxable year to June 30.
Insert appropriate Line Code and tax rate for reportable business activity.
Accrual Basis taxpayers may reduce their Column 1 Total Gross Proceeds by Column 2 Bad Debt and Column 3 Contractual
Allowance deductions to the extent that they were included in gross receipts upon which the tax imposed was paid.
Cash Basis taxpayers may not claim Column 2 Bad Debt and Column 3 Contractual Allowance deductions
*H04100702A*
PAGE 2
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