Montana Form Id-Nh - Nursing Home Income And Expense Reporting Form Page 2

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Income and Expense Data (cont.)
Project Amenities
(Check any that may apply.)
Swimming pool
Sauna/hot tub
Dishwasher
Shops
Fenced
Tennis courts
Washer/dryer
Coffee shop
Game room
RV waste disposal
Clubhouse
Range
Restaurant
Beauty shop
Night lights
Exercise room
Refrigerator
Bar
Guest laundry
Heated units
Covered parking
Storage
Casino
Convenience store
On-site offi ce
Expense Responsibilities
Owner
Tenant
Shared
Owner
Tenant
Shared
Cleaning
Cable TV
Trash removal
Electric
Building maintenance
Gas
Parking lot maintenance
Water
Nursing Home/Assisted Living Accommodations or Boarding House
Monthly
Utilities included in rent (check all that apply)
Private
Accommodations
market
# of units
bath
Electric
Water
Gas
Cable TV
rent
Full-care 1 occupant per room
Full-care 2 occupants per room
Assisted living 1 occupant per room
Assisted living 2 occupant per room
Effi ciency apartments
1 bedroom apartments
2 bedroom apartments
Cottages
Please be advised that you are required to report if you have business equipment with a market value of $100,000 or more. If you have
or have recently acquired business equipment with a market value that exceeds $100,000, please check the box below to receive a
business equipment reporting form if one has not already been provided to you.
Please send me a business equipment reporting form.
▲
▲
revenue.mt.gov
Toll free 1-866-859-2254 (in Helena, 444-6900)
TDD (406) 444-2830

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