HCP-4
State of Rhode Island and Providence Plantations
Department of Revenue - Division of Taxation
HOSPITAL
LICENSING
HOSPITAL LICENSING FEE REPORT
Due on June 18, 2012
FEE
NAME
ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON
TITLE
PHONE NUMBER
FEDERAL IDENTIFICATION NUMBER
EMAIL ADDRESS
RETURN FOR THE PERIOD OF:
O
1, 2009
S
30, 2010
CTOBER
THROUGH
EPTEMBER
Calculation of Amount Due:
1.
Gross Patient Services Revenue (See instructions) ................................
1.
2.
Amount of Charity Care, Bad Debts Expense and Contract Allowances..
2.
3.
Net Patient Services Revenue - Line 1 minus Line 2 .................................................................................
3.
4.
Net Licensing Fee Due - Line 3 times 5.43% (0.0543) ..........................................................................
4.
5.
Interest - (1.5% per month) See instructions ..............................................................................................
5.
6.
Penalty - (10%) See instructions ................................................................................................................
6.
7.
TOTAL AMOUNT DUE (Add lines 4, 5 and 6) ...........................................................................................
7.
INSTRUCTIONS
NOTE: AS OUTLINED IN R.I.G.L. 23-17-38.1, THIS RETURN
Line 4: Net Licensing Fee Due - Multiply Line 3 times 5.43%
IS DUE BY JUNE 18, 2012 EVEN THOUGH THE
(0.0543).
REMITTANCE IS NOT DUE UNTIL JULY 16, 2012.
Line 5: Interest - If remitting after July 16, 2012, multiply Line 4
Line 1: Gross Patient Services Revenue - Enter the amount
times 1.5% (0.015) times the number of months late.
reported on Line 1 of Worksheet G3, Medicare Hospital
Interest is calculated from July 16, 2012 to the date of
and Hospital Health Care Complex Cost Report for the
remittance at a rate of 18% per annum.
Hospital Fiscal Year ending September 30, 2010.
Line 6: Penalty - If remitting after July 16, 2012, multiply Line 4
Line 2: Deductions - Enter the amount of Charity Care, Bad
times 10% (0.10). Penalty is calculated at 10% of the
Debts Expense and Contract Allowances.
net licensing fee due.
Line 3: Net Patient Services Revenue - Line 1 minus Line 2.
Line 7: Total Amount Due - Add line 4, 5 and 6.
PAYMENTS MUST BE MADE BY ELECTRONIC FUNDS TRANSFER (EFT).
QUESTIONS REGARDING EFT TRANSFERS MAY BE DIRECTED TO (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 02908-5811
revised 06/21/2011