Form Wv/hcp-3a - West Virginia Annual Return Of Broad Based Health Care Related Taxes 2008 Page 3
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1
2
32008
WV ANNUAL RETURN OF BROAD
FEIN
BASED HEALTH CARE RELATED TAXES
PERIOD
PERIOD
ENDING
BEGINNING
MM
DD
MM
YYYY
DD
YYYY
SCHEDULE C COMPUTATION OF TAX
LINE
COL 1
COL 5
TAXABLE
COL2
COL 4 - TAXABLE GROSS
COL 6
CODE
TOTAL GROSS
RATE
SERVICE
BAD DEBT
PROCEEDS
TAX DUE
PROCEEDS
(COL 1 - COL 2 & 3)
COL 4 X COL 5
5.5%
Nursing Facility
99
PERIOD
PERIOD
BEGINNING
ENDING
DD
DD
MM
YYYY
YYYY
MM
COL 5
COL 1
COL 4 - TAXABLE GROSS
COL 6
COL2
LINE
TAXABLE
RATE
TOTAL GROSS
PROCEEDS
TAX DUE
BAD DEBT
CODE
SERVICE
PROCEEDS
(COL 1 - COL 2 & 3)
COL 4 X COL 5
Nursing Facility
8
5.95%
SCHEDULE C TOTAL TAX DUE (ADD COL 6 FOR LINE CODES 99 AND 8) ENTER HERE AND ON SCHEDULE E LINE 3
PERIOD
PERIOD
ENDING
BEGINNING
SCHEDULE D COMPUTATION OF TAX
YYYY
DD
MM
DD
MM
YYYY
COL 6
COL 1
COL2
COL 3
COL 4 - TAXABLE GROSS
COL 5
LINE
TAXABLE
PROCEEDS
TAX DUE
TOTAL GROSS
BAD DEBT
CONTRACTUAL
RATE
CODE
SERVICE
(COL 1 - COL 2 & 3)
COL 4 X COL 5
PROCEEDS
ALLOWANCES
Chiropractic
Dental
Emergency
Ambulance
Nursing
Optician
Optometry
Physician
Podiatry
Psychological
Therapists
SCHEDULE D TOTAL TAX DUE (ADD COL 6 FOR ALL TAXABLE SERVICES) ENTER HERE AND ON SCHEDULE E LINE 4
SCHEDULE E TOTAL ANNUAL TAX
1. TAX DUE FROM SCHEDULE A..........................................
2. TAX DUE FROM SCHEDULE B.........................................
3. TAX DUE FROM SCHEDULE C.........................................
4. TAX DUE FROM SCHEDULE D........................................
5. TOTAL ANNUAL TAX - ADD LINES 1 THROUGH 4. ENTER HERE AND ON PAGE 1 LINE 1
SCHEDULE C.
Report revenue from the beginning of your taxable year to October 31 for Line Code 99.
Report revenue from November 1 to the end of your taxable year for Line Code 8.
Accrual Basis taxpayers may reduce their Column 1 Total Gross Proceeds by Column 2 Bad Debt deductions only to the
extent that they were included in gross receipts upon which the tax imposed was paid. Deductions for Contractual
Allowances may not be claimed.
SCHEDULE D.
Insert appropriate Line Code and tax rate for reportable business activity.
Report revenue from July 1 to the end of your taxable year.
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
*H04100703A*
PAGE 3
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