Annual Return Of Broad Based Health Care Related Taxes Page 3
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4ANNUAL RETURN OF BROAD BASED HEALTH CARE RELATED TAXES
WV/HCP-3A
rtL080 v.10-Web
SCHEDULE C - COMPUTATION OF TAX FOR TAXABLE PERIOD JULY 1 THRU DECEMBER 31
LINE
TAXABLE
COL 1
COL 2
COL 3
COL 4
COL 5
COL 6
CODE
SERVICE
TOTAL GROSS
BAD DEBT
CONTRACTUAL
TAXABLE GROSS
RATE
TAX DUE
PROCEEDS
ALLOWANCES
PROCEEDS
COL 4 X COL 5
COL 1 - COL 2 & 3
2
Chiropractic
.
.
.
.
.
3
Dental
.
.
.
.
.
Emergency
4
.
.
.
.
.
Ambulance
9
Nursing
.
.
.
.
.
10
Optician
.
.
.
.
.
11
Optometry
.
.
.
.
.
13
Physician
.
.
.
.
.
14
Podiatry
.
.
.
.
.
15
Psychological
.
.
.
.
.
16
Therapists
.
.
.
.
.
SCHEDULE C TOTAL TAX DUE
.
(ADD COL 6 FOR ALL TAXABLE SERVICES) ENTER HERE AND ON SCHEDULE D LINE 3
SCHEDULE D - TOTAL ANNUAL TAX
1.
TAX DUE FROM SCHEDULE A
.
2.
TAX DUE FROM SCHEDULE B
.
3.
TAX DUE FROM SCHEDULE C
.
4.
TOTAL ANNUAL TAX - ADD LINES 1 THROUGH 3. ENTER HERE AND ON PAGE 1 LINE 1.
.
SEE INSTRUCTIONS ON PAGE 4
G
1
6
2
0
0
8
0
3
W
PAGE 3 OF 4
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