Form Hcp-65 - Imaging Services Surcharge Return
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1HCP-65
State of Rhode Island and Providence Plantations
Department of Revenue - Division of Taxation
IMAGING
IMAGING SERVICES SURCHARGE RETURN
SERVICE
Due on or before the 25th day of the following month
SURCHARGE
NAME
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
FEDERAL EMPLOYER IDENTIFICATION NUMBER
RETURN FOR THE PERIOD OF:
MONTH
YEAR
Calculation of Amount Due:
1.
Net patient imaging revenue received ........................................................................................................
1.
2.
Imaging services surcharge - line 1 time 2% (0.02) ...................................................................................
2.
3.
Interest - (1.5% per month) see instructions ..........................................................
3.
4.
Penalty - (10%) see instructions .............................................................................
4.
5.
Total Interest and penalty amount ..............................................................................................................
5.
6.
TOTAL AMOUNT DUE (Add lines 2 and 5) ................................................................................................
6.
INSTRUCTIONS
Line 1: Net Patient Imaging Revenue Received - Enter the
Line 4: Penalty - If remitting after the due date, multiply Line 2
amount of all monies and other consideration received
time 10% (0.10). Penalty is calculated at 10% of the
for the provision of imaging services for the month being
surcharge due.
reported on this return.
Line 5: Total Interest and Penalty Amount - Add lines 3 and 4.
Line 2: Imaging Services Surcharge - Multiply Line 1 times
2.0% (0.02)
Line 6: Total Amount Due - Add line 2 and 5.
Line 3: Interest - If remitting after the due date, multiply Line 2
EFFECTIVE OCTOBER 31, 2007, PAYMENTS MUST BE MADE
times 1.5% (0.015) times the number of months late.
BY ELECTRONIC FUNDS TRANSFER (EFT). QUESTIONS
Interest is calculated from the due date of the return to
REGARDING EFT TRANSFERS MAY BE DIRECTED TO
the date of remittance at a rate of 18% per annum.
(401)574-8484.
Under penalties of perjury, I hereby certify that I have personal knowledge of the statements and other information constituting this return, that the same are true,
correct and complete to the best of my knowledge and belief.
Date
Signature of authorized officer
Title
Date
Signature of preparer
Address of preparer
MAY THE DIVISION CONTACT YOUR PREPARER ABOUT THIS RETURN? YES
NO
Phone number
MAILING ADDRESS: RHODE ISLAND DIVISION OF TAXATION, ONE CAPITOL HILL, PROVIDENCE, RI 02908-5814
Key #75
revised 9/28/2011
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