Form Cdi Fs-008 - Medi-Cal Managed Care Plan Insurance Tax Return - State Of California
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3State of California
Department of Insurance
MEDI-CAL MANAGED CARE PLAN INSURANCE TAX RETURN
CDI FS-008 (NEW 9/2011)
2011
FOR CALENDAR YEAR
TAX DUE DATE APRIL 1, 2012
Name of Insurer/ Medi-
Fed Tax I.D. No.
CA Perm No.
Cal Managed Care Plan
Mailing Address
EFT Taxpayer I.D. No.
City, State, Zip
Method of Tax Payment
No 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 2011
CDI use only
1.
Total Operating Revenue (from Schedule A, line 5)
1.
2.35%
2.
Tax Rate
2.
3.
2011 Annual Tax
3.
4.
Prepayments Made During the Reporting Year of 2011
a.
Overpayment applied from prior year
b.
First Quarter (Balance paid)
c.
Second Quarter
d.
Third Quarter
e.
Fourth Quarter
5.
Total Prepayments Made
5.
6.
2011 Tax Due - If Line 3 is greater than Line 5
6.
7.
2011 Tax Overpayment- If Line 5 is greater than Line 3
7.
The tax overpayment (line 7) may be applied to the 2012 first
quarter prepayment.
A Refund SHALL NOT be applied to the 2012 second quarter
prepayment or any future tax payment.
8.
2012 First Quarter Prepayment
8.
a.
2011 Tax Overpayment applied to the 1st Quarter Prepayment
a.
b.
2012 First Quarter Prepayment Balance Due
8b.
9.
Tax Refund
9.
Line 6
2011 Tax Due
Line 8.b
2012 First Quarter Prepayment Balance Due
Each Payment must be paid separately and should
NOT be combined to make one lump sum payment
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