Form Nfbt - Nursing Facility Bed Tax
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2
3MONTANA
NFBT
Rev._2-07
Nursing Facility Bed Tax
15-60-101,_MCA
Return_and_Instructions
Rate_Effective_July_1,_2006_to_June_30,_2007
Name____________________________________________________________________
Address__________________________________________________________________
Address__________________________________________________________________
City,_ST,_ZIP_ _ _____________________________________________________________
1._ FEIN_
4._ If_this_is_an_amended_return,_check_here
2._ Account_ID_
5._ If_you_are_no_longer_in_business_and_want_your_account__
cancelled, enter the final date
3._ Quarter_Ending:_
6._ If_your_mailing_address_has_changed,_check_the_box__
_
_
_
and_print_new_address_below:
_
Due:
_
a._
b._
c._
d._
e._
f.
s
Bed_Days_
Bed_Days_
Bed_Days_
Bed_Days__
Bed_Days_
Bed_Day
Available_
Occupied_
Medicaid_
Medicare_
Other_
Private_Pay
7. First Month......................
8. Second Month .................
9. Third Month ....................
10. Quarter Total . ...................
11. Total bed days subject to tax (Total of line 10 columnb b)
Column b must equal totals of columns c, d, e and f ................................................ ______________
12. Total tax due (line 11 times tax rate of $8.30) . .......................................................... ______________
13. Penalty . ...................................................................................................................... ______________
14. Interest . ...................................................................................................................... ______________
15. Total tax due (lines 12, 13, and 14) ........................................................................... ______________
Signature ______________________________________________
Title __________________________________________________
Phone___________________________ Date__________________
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