Form Icfuf - Intermediate Care Facility Utilization Fee
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1MONTANA
Form ICFUF
Rev. 4-05
Intermediate Care Facility Utilization Fee
Quarter ending _____/_____/_____
Federal ID #__________________
Name and address of intermediate care facility
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
1. Total facility expenditures for quarter .......................... $_______________
2. Line 1 times 6% (.06) .................................................. $_______________
3. Total number of resident bed days for quarter ............ ________________
4. Utilization fee per resident bed day
(line 2 divided by line 3) .............................................. $_______________
5. Total utilization fee due (line 3 times line 4) ..................................................... $_______________
6. Penalty and interest ........................................................................................ $_______________
7. Total paid with return ....................................................................................... $_______________
________________________________________
_________________
________________
Signature of preparer
Date
Phone
Retain a copy for your records. Statement and remittance for any tax due must be received on or
before the last day of the month following the end of each calendar quarter. If you have an ques-
tions, please call or write to:
Montana Department of Revenue
PO Box 5835
Helena, MT 59604-5835
(406) 444-6900
345
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Parent category: Financial