Form Nfbt - Nursing Facility Bed Tax (Page 3 of 3) in pdf

Form Nfbt - Nursing Facility Bed Tax Page 3

Nursing Facility Bed Tax

(NFBT)

Payment Instructions

Attention: Montana Department of Revenue Cashier

Complete the payment coupon below to ensure proper credit of your payment. If you are paying taxes for multiple

periods, submit a separate check or money order and a separate coupon for each period. On the memo line of your

check, please note your FEIN or account ID and the reporting period for which the payment applies.

Boxes 1 and 2 – Print an “X” in one box only for the type of payment you are remitting:

Check box 1, if your payment is for an original return for any period.

Check box 2, if your payment is for an amended return.

Box 3 – Enter the reporting period for which this payment applies.

Box 4 – Enter your federal employer identification number (FEIN).

Box 5 – Enter the amount you are remitting. (This amount should be the same amount as reported on line 15 of your

return).

Name _______________________________________________________________

Address ______________________________________________________________

______________________________________________________________

City, State, Zip Code ______________________________________________________

Phone ________________________________________________________________

Mail this entire form with your check or money order and return to:

Department of Revenue

PO Box 5835

Helena, MT 59604-5835

Questions? Call (406) 444-6900.

Make check or money order payable to the Department of Revenue.

Montana Nursing Facility Bed Tax

Payment Form

1. Original return

month

day

year

2. Amended return

3. Period ending

4. Federal employer

identification

number (FEIN)

5. Amount paid

Form Nfbt - Nursing Facility Bed Tax Page 3