Form Cdi Fs-008 - Medi-Cal Managed Care Plan Insurance Tax Return - State Of California Page 3
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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
SCHEDULE A
1.
Total Operating Revenue
1.
$
Contract Number:
County:
$
County:
$
Contract Number:
County:
$
County:
$
Contract Number:
County:
$
County:
$
2.
Other Operating Revenue
- (
)
2.
Please Specify
3.
Total Operating Revenue for all Contracts
3.
4.
DEDUCT Revenue Received and/or Accrued not Subject to Assessment
4.1
Medicare Revenue
4.1
4.2
Amounts Received from another Medi-Cal Managed Care Plan
4.2
- (
)
4.3
Other Revenue
Please Specify
4.3
4.4
Total Revenue not subject to Assessment
4.4
5.
Taxable Operating Revenue. Deduct Line 4.4 from Line 3.
5. $
Forward to Page 1, Line 1
Page 3 of 3
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