Form Fr-500 - Combined Registration Application For Business (Page 3 of 3) in pdf

Form Fr-500 - Combined Registration Application For Business Page 3

PART VIII, Section 5 — Medicaid Hospital Outpatient Supplemental Payment

Yes

Begin date (MMDDYYYY) ____/____/________

End date (MMDDYYYY) ____/____/________

PART VIII, Section 6 — Medicaid Hospital Inpatient Rate Supplement

Yes

Begin date (MMDDYYYY) ____/____/________

End date (MMDDYYYY) ____/____/________

PART IX — Miscellaneous Tax Registration

Check applicable block(s) and the appropriate payment booklets/returns will be sent to you. Additional information and materials are also available

on our website at

Alcoholic Beverage Wholesaler

Gross Receipts Tax on Heating Oil

Cable Television, Satellite Relay or Distribution of Video or Radio Transmission only

Interstate Bus

Cigarette Wholesaler

Motor Vehicle Fuel Tax

Commercial Mobile Service Tax

Gross Receipts Tax on Natural or Artificial Gas by

o r

s s

e c

p i

s t

c i l

i l i

y t

P -

c i l

i l i

y t

r e

o s

Gross Receipts Tax on Toll Telecommunication Service

If you have questions please contact the Customer Service Administration at (202) 727-4TAX (4829) or by email taxhelp@dc.gov.

CERTIFICATION

I declare under penalties as provided by law that this application (including any accompanying schedules and statements) has been examined

by me and, to the best of my knowledge, it is correct.

g i

u t

e r

t i

e l

e t

APPLICATIONS WHEN COMPLETED MUST BE SIGNED BY EITHER THE OWNER, PARTNER OR PRINCIPAL OFFICER OF THE CORPORATION.

Articles of Incorporation or Articles of Organization must be provided with this application

AGENTS or REPRESENTATIVES SIGNING MUST ATTACH A POWER OF ATTORNEY FORM D-2848

OFFICIAL USE ONLY

Type Date Lia.

Tax

began

Cycle

Method

Remarks

MISC

Reviewer/Date

Date Data Entered/Initials

Form Fr-500 - Combined Registration Application For Business Page 3

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