Form Rct-113b - Gross Receipts Tax (Grt) Report Managed Care Organizations

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No dashes (-) or slashes (/) to be used in any fields, this includes Date, FEIN, Phone and ZIP
1130212105
OFFICIAL USE ONLY
RCT-113B
PAGE 1 OF 2
Date Received (Official Use Only)
(06-12)
GROSS RECEIPTS TAX (GRT) REPORT
MANAGED CARE ORGANIZATIONS
Tax Year Begin:
START
Revenue ID
Federal ID (FEIN)
Parent Corporation (FEIN)
Tax Year End:
12/31/20
_ _
Due Date: March 15
Please select correct letter in drop down
Taxpayer Name
Check to Indicate a Change of Address
Send All Correspondence to the Preparer
First Line of Address
Amended Report
First Report
Second Line of Address
Payment Made Electronically
City
State
ZIP
Last Report
Phone
Out of Existence as of:
Email
*1 1 3021 21 05*
USE WHOLE DOLLARS ONLY
1.
Gross Receipts Tax Managed Care Organizations (Page 2, Line 2)
1.
2.
Total Estimated Payments
2.
3.
Total Payments Carried Forward From Prior Year Return
3.
4.
Total “Restricted” Tax Credits
4.
5.
Total Credit: (Line 2 plus Line 3 plus Line 4)
5.
6.
Tax Due: (If Line 1 is more than Line 5, enter the difference here.)
6.
7.
Remittance: (Include interest and penalty, if applicable.)
7.
8.
OVERPAYMENT: (If Line 5 is more than Line 1, enter the difference here.)
8.
9.
Refund: (Amount of Line 8 to be refunded after offsetting all unpaid liabilities)
9.
10. Transfer: (Amount of Line 8 to be credited to the next tax year after offsetting
10.
all unpaid liabilities)
Corporate Officer Information:
Social Security
Number of Officer
Officer Last Name
Officer First Name
Phone
Title of Officer
Email
I affirm under penalties prescribed by law this report, including any accompanying schedules and statements, has been examined by me and to the best of my
knowledge and belief is a true, correct and complete report. If this report is an amended report, the taxpayer hereby consents to the extension of the assessment
period for this tax year to one year from the date of filing of this amended report or three years from the filing of the original report, whichever period last expires,
and agrees to retain all required records pertaining to that tax and tax period until the end of the extended assessment period, regardless of any statutory
provision providing for a shorter period of retention. For purposes of this extension, an original report filed before the due date is deemed filed on the due date.
I am authorized to execute this consent to the extension of the assessment period.
Signature of Officer
Date
Signature of Officer – Please sign after printing
Reset Entire Form
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