Form Rct-113b - Gross Receipts Tax (Grt) Report Managed Care Organizations Page 2

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1130212205

Revenue ID

RCT-113B

PAGE 2 OF 2

(06-12)

SOURCE OF GROSS RECEIPTS

USE WHOLE DOLLARS ONLY

Gross Receipts from GRT MMCO Revenue Report issued by the

Department of Public Welfare

Managed Care Organizations GRT (Line 1 times tax rate - See Instructions)

*1 1 3021 2205*

Preparer’s Information:

Firm Name

Individual Preparer Name

Firm FEIN

Phone

Address

City

Social Security Number

or PTIN

State

ZIP

I affirm under penalties prescribed by law this report, including any accompanying schedules and statements, has been prepared by me and to the best of my

knowledge and belief is a true, correct and complete report.

Signature of Preparer

Date

Signature of Preparer – Please sign after printing

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