Form Hcp-1 - Health Care Provider Tax Return printable pdf download

HCP-1

State of Rhode Island and Providence Plantations

Department of Revenue - Division of Taxation

GROUP

HOMES

HEALTH CARE PROVIDER TAX RETURN

RETURN

Due on or before the 25th day of the following month

NAME

ADDRESS

CITY

STATE

ZIP CODE

PHONE NUMBER

FEDERAL IDENTIFICATION NUMBER

RETURN FOR THE PERIOD OF:

MONTH

YEAR

AME OF

ACILITY

OTALS

ICENSE

UMBER OF

ACILITY

1: R

INE

ESIDENT

ARE

ERVICE

NCOME

ROM

ROVIDING

OUR A

ERVICE

2: R

5.5%

INE

ATE

3: T

INE

TIMES

INE

4: I

INE

NTEREST

5: P

INE

ENALTY

6: T

INE

OTAL

3, 4

INES

AND

INSTRUCTIONS

Line 1: Resident Care Service Income from Providing 24

Line 4: Interest - Interest is calculated from the due date of the

Hour a Day Service - Enter the amount of cash receipts

return to the date of remittance at a rate of 18% per

for Resident Care Service from the State of Rhode

annum. If remitting after the due date, multiply Line 3

Island provided on a twenty-four hour basis for individu-

times 1.5% (0.015) times the number of months late.

als with developmental disabilities.

Line 5: Penalty - If remitting after the due date, multiply Line 3

Line 2: Rate - The applicable rate for a Residential Care Facility

times 10% (0.10). Penalty is calculated at 10% of the

or Residential Provider is 5.5%.

tax due.

Line 3: Tax Due - Multiple Line 1 times Line 2.

Line 6: Total Amount Due - Add lines 3, 4 and 5.

PROVIDERS WITH MORE THAN SIX (6) RESIDENTIAL CARE FACILITIES SHOULD

COMPLETE MORE THAN ONE RETURN, BUT ONLY ONE TOTAL COLUMN.

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

Phone number

MAILING ADDRESS: RHODE ISLAND DIVISION OF TAXATION, ONE CAPITOL HILL, PROVIDENCE, RI 02908-5811

#35

revised 2/6/2009

Form Hcp-1 - Health Care Provider Tax Return

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