Electronic Funds Transfer (Eft) Authorization - Minnesota Department Of Revenue Page 13
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152001
MINNESOTA Department of Revenue
Record of 2001 MinnesotaCare Tax Payments
Record the tax payments you make for 2001 on this form, and use it when you prepare your 2001
MinnesotaCare annual tax return. Keep this payment record with your 2001 tax records.
Do not include:
• Payments made to the department for any other business taxes
• Payments for a balance due on previous years’ MinnesotaCare taxes
• Payments made on an audit report or amended return
• Payments made for penalties or interest
Health-care providers — Record of quarterly tax payments
Confirmation number/
Payments due:
check number
Date paid
Amount paid
April 16, 2001
July 16, 2001
October 15, 2001
January 15, 2002
Total of quarterly tax payments made for 2001 . . . . . . . . . . . . . . . . . . . . $
Hospitals and surgery centers — Record of monthly tax payments
Confirmation number/
Payments due:
check number
Date paid
Amount paid
February 15, 2001
March 15, 2001
April 16, 2001
May 15, 2001
June 15, 2001
July 16, 2001
August 15, 2001
September 17, 2001
October 15, 2001
November 15, 2001
December 17, 2001
January 15, 2002
Total of monthly tax payments made for 2001 . . . . . . . . . . . . . . . . . . . . $
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