Form Hcp-1 - Health Care Provider Tax - Estimate Payment Voucher

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HCP-Est
Maine Revenue Services
031480000
Health Care Provider Tax
Estimate Payment Voucher
Registration No.
Fiscal Year
Due Date
1. Entity Information
Any change in ownership, address or name should be addressed in correspondence and attached to this voucher.
Section 1: Complete this section only for the initial return and every July period thereafter.
Check one only
We elect to estimate our tax liability based on net operating revenue for the current state fiscal year.
We elect to estimate our tax liability based on a fiscal year where taxable revenues have been finally
determined and are no longer open to audit adjustment.
Month
Year
If the second option is used, the finalized period's fiscal year began
Section 2:
Monthly estimated payment due for month of
1.
1.
,
.
Less: Prior Credit (if any)
2.
2.
,
.
Total Remittance with return (line 1 less line 2; if less than zero, enter zero
3.
3.
,
.
Mail To:
Maine Revenue Service
P.O. Box 1064
Augusta, ME 04332-1064
Signature
Title
Date
Phone #
HCP-1 Revised 03/03

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