Form Cdi Fs-008 - Medi-Cal Managed Care Plan Insurance Tax Return - 2013
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3State of California
Department of Insurance
MEDI-CAL MANAGED CARE PLAN INSURANCE TAX RETURN
CDI FS-008 (REV 12/2013)
2013
FOR CALENDAR YEAR
TAX DUE DATE APRIL 1, 2014
Name of Insurer/ Medi-
Fed Tax I.D. No.
CA Perm No.
Cal Managed Care
Mailing Address
EFT Taxpayer I.D. No.
City, State, Zip
Method of Tax
No Payment
Payment
Telephone & Fax #
Check
State of Domicile
EFT
If Final Return, check here
If Amended Return, check here
and indicate the effective date of the final transaction.
and indicate the date when it was amended.
STATEMENT OF TAXABLE REVENUE AND TAXES DUE DURING CALENDAR YEAR 2013
CDI Use Only
1,000.00
1.
Total Operating Revenue (from Schedule A, line 5)
1.
2.35%
2.
Tax Rate
2.
23.50
3.
2013 Annual Tax
3.
4.
Retroactive Payments received during 2013 for service periods
100.00
a.
January to December, 2009
200.00
b.
January to December, 2010
300.00
c.
January to December, 2011
400.00
d.
January to December, 2012
1,000.00
e. Total Retroactive Payments Received
4.e
2.35%
5.
Tax Rate
5.
23.50
6.
2013 Retroactive Tax Due
6.
30.00
7.
2013 Tax Payment(s) Made
7.
17.00
8.
Tax Due or (Refund)
8.
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