Form Rpd-41292 - Daily Bed Surcharge Return printable pdf download

State of New Mexico

RPD-41292

Rev. 11/2007

Taxation and Revenue Department

DAILY BED SURCHARGE RETURN

WHO MUST FILE: Beginning July 1, 2004, and ending June 30, 2007, the daily bed surcharge is imposed on licensed

nursing homes, licensed intermediate care facilities for the mentally retarded, and licensed residential treatment centers*.

A health care business operating one or more licensed nursing homes, licensed intermediate care facility for the mentally

retarded, or licensed residential treatment center must use this monthly report to pay the daily bed surcharge to the New

Mexico Taxation and Revenue Department. Do not file this form if no tax is due.

*The rate is zero for licensed residential treatment centers and no return is required to be filed. Others see the table in the

instructions for the effective rate for each fiscal year to date.

WHEN TO FILE: The daily bed surcharge is due on or before the 25th day of the month following the close of the report

period. A report period is a calendar month.

Mail this form, required attachments and payment to: New Mexico Taxation and Revenue Department, P.O. Box 25123,

Santa Fe, NM 87504-5123. Make the check or money order payable to New Mexico Taxation and Revenue Department.

For assistance call (505) 827-0725.

REPORT PERIOD:

Beginning (mm/dd/yy)

Ending (mm/dd/yy)

FEIN:

Indicate no. of facilities reporting

CRS:

1. No. occupied bed days

NAME:

2. Effective rate

STREET/BOX:

3. Surcharge

4. Penalty

CITY, STATE, ZIP:

5. Interest

6. Total due

Check if amended

PLEASE CUT AND INCLUDE THE BOTTOM PORTION WITH YOUR PAYMENT

RETAIN THE UPPER PORTION FOR YOUR RECORDS

DAILY BED SURCHARGE