Form Rpd-41292 - Daily Bed Surcharge Return - New Mexico Taxation And Revenue Department
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2RPD-41292
State of New Mexico
Rev. 09/2004
Taxation and Revenue Department
DAILY BED SURCHARGE RETURN
WHO MUST FILE: Beginning July 1, 2004, and ending June 30, 2007, the daily bed surcharge is imposed on licensed nursing
homes, licensed intermediate care facilities for the mentally retarded, and licensed residential treatment centers. A health care
business operating one or more licensed nursing homes, licensed intermediate care facility for the mentally retarded, or licensed
residential treatment center must use this monthly report to pay the daily bed surcharge to the New Mexico Taxation and Revenue
Department. Do not file this form if no tax is due.
WHEN TO FILE: The daily bed surcharge is due on or before the 25th day of the month following the close of the report period.
A report period is a calendar month.
Mail this form, required attachments and payment to: New Mexico Taxation and Revenue Department, P.O. Box 25123, Santa
Fe, NM 87504-5123. Make the check or money order payable to New Mexico Taxation and Revenue Department. For assistance
call (505) 827-0725.
REPORT PERIOD:
Beginning (mm/dd/yy)
Ending (mm/dd/yy)
FEIN:
Indicate no. of facilities reporting
CRS:
1.
1. No. occupied bed days
NAME:
2.
$
2. Effective rate
STREET/BOX:
3.
$
3. Surcharge
4.
$
4. Penalty
CITY, STATE, ZIP:
5.
$
5. Interest
6.
$
6. Total due
Check if amended
PLEASE CUT AND INCLUDE THE BOTTOM PORTION WITH YOUR PAYMENT
RETAIN THE UPPER PORTION FOR YOUR RECORDS
DAILY BED SURCHARGE
REPORT PERIOD:
Beginning (mm/dd/yy)
Ending (mm/dd/yy)
FEIN:
Indicate no. of facilities reporting
CRS:
1. No. occupied bed days
1.
NAME:
2.
$
2. Effective rate
STREET/BOX:
3.
$
3. Surcharge
4.
$
4. Penalty
CITY, STATE, ZIP:
5.
$
5. Interest
6.
$
6. Total due
Check if amended
Signature ___________________________________ Date _____________ Phone ___________
DBS
Mail To:
Taxation and Revenue Department, P.O. Box 25123, Santa Fe, NM 87504-5123
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