Form Mdca - Medical Device Credit Application

Form Mdca - Medical Device Credit Application - 2013

2013

Form MDCA

Massachusetts

Medical Device

Department of

Credit Application

Revenue

For calendar year 2013 or taxable year beginning

and ending

Medical device company name

Federal Identification or Social Security number

Mailing address

City/Town

State

Zip

Name of contact person

Telephone

E-mail address

1 Type of medical device company:

Corporation

Trust

Partnership

Sole proprietorship

LLC

Other

2 Qualified user fees paid to U.S. Food and Drug Administration during the taxable year. (“Qualified user fees” are “user fees” as defined in TIR 06-22.)

Note: Include only those qualified user fees related to new medical devices or to upgrades, changes or enhancements to existing medical devices,

developed or manufactured in Massachusetts. A new medical device or an upgrade, change or enhancement to an existing medical device is “developed

or manufactured in Massachusetts” if more than 50% of the development or manufacturing costs associated with the

medical device or the upgrade, change or enhancement are incurred in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Date(s) of qualified user fee payment(s)

4 Address of Massachusetts plant or facility

5 Brief description of medical device(s) to which the user fees above relate

6 Percentage of development or manufacturing costs incurred in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Note: Attach copies of all USDA Department of Health and Human Services Food and Drug Administration Medical Device User Fee Cover Sheets asso-

ciated with this application.

I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.

Signature

Date

Mail to: Massachusetts Department of Revenue, Audit Division, 200 Arlington Street, Room 4300, Chelsea, MA 02150, attn.: Medical Device Unit.