Form Dp-158 - Intermediate Care Facility (Icf) Quality Assessment Return
Download a blank fillable Form Dp-158 - Intermediate Care Facility (Icf) Quality Assessment Return 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 Dp-158 - Intermediate Care Facility (Icf) Quality Assessment Return 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
1FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
DP-158
INTERMEDIATE CARE FACILITY (ICF) QUALITY ASSESSMENT RETURN
821
2010
2011
Other ___________
FOR DRA USE ONLY
For Assessment
Period: Check One
January 1-March 31
April 1-June 30
July 1-September 30
October 1-December 31
FACILITY NAME
FEDERAL EMPLOYER IDENTIFICATION NUMBER
STEP 1
NUMBER AND STREET ADDRESS
ADDRESS (continued)
CITY/TOWN STATE & ZIP CODE+4
STEP 2
Check the type of return
Return
INITIAL RETURN
AMENDED RETURN
FINAL RETURN
LAST DAY OF BUSINESS
Type
MO
DAY
YEAR
STEP 3
1 Net Patient Services Revenues .................................... 1
Figure
Your
Assess-
2 New Hampshire ICF Quality Assessment ...............................................................................2
ment
[Line 1 x 5.5% (.055)]
STEP 4
3 Credits: (a) Payment made with extension................ 3(a)
Credits
Interest
(b) Credit carried over from prior period ......... 3(b)
and
Penalties
(c)
Original Return Payment ...................... 3(c)
(
Amended returns only)
TOTAL [Sum of Line 3(a) through Line 3 (c)] ............... 3
4 BALANCE OF ASSESSMENT DUE (Line 2 less Line 3) .........................................................4
5 Additions
(a) Interest .................................................... 5(a)
(b) Failure to Pay Penalty ............................ 5(b)
(c)
Failure to File Penalty ............................. 5(c)
5 TOTAL [Sum of Line 5(a) through Line 5(c)] ............................................................................5
STEP 5
6 Balance Due (Line 4 plus Line 5) ............................................................................................ 6
Balance
Due
STEP 6
NOTE: Do Not complete Step 6, Lines 7-10, unless you are fi ling an amended return.
For
7 Payments Made by Electronic Transfer ....................... 7
Amended
Returns or
Overpay-
8 Adjusted BALANCE DUE [Line 6 minus Line 7]. Do not pay if less than $1.00 .....................8
ment
If a negative amount, enter zero and go to Line 9.
ONLY
9 Overpayment................................................................ 9
(Line 2 minus Line 3 plus Line 5, minus Line 7 if applicable)
10 Apply Overpayment to Credit on subsequent return payment ..................................................10
STEP 7
Under penalties of perjury, I declare that I have examined this return and to the best of my belief it is true, correct and complete. If
SIGNATURES
prepared by a person other than the authorized ICF Representative, this declaration is based on all information of which the preparer
has knowledge.
FOR DRA USE ONLY
Signature Of Offi cer (in ink)
Date
Signature (in ink) of Paid Preparer Other Than Facility Representative
Print Signatory Name & Title
NH DRA
MAIL
DOCUMENT PROCESSING DIVISION
TO:
PO BOX 1004
Preparer’s Tax Identifi cation Number
Date
CONCORD NH 03302-1004
Preparer’s Address
City/Town, State & Zip Code+4
DP-158
Rev 02/2011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial