Tax Disclosure Report Preferred Provider Companies - The Commonwealth Of Massachusetts Page 2

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In these instructions, all references to Massachusetts tax forms refer to 2014 forms. If you are using forms for any other year when supplying informa-

tion, be sure that you include the substantive information required by statute. Forms for other years may be numbered differently.

INSTRUCTIONS FOR COMPLETION OF THIS FORM

Note: The information for this filing must come from your most recently filed tax return or other document filed on or before June 30, 2016.

Please type or print clearly in ink as this document will be microfilmed. Incomplete or incorrect reports will be returned to sender for completion and/or correction.

Please send original document only; keep a photocopy for your files.

A. Insert Federal Identification Number (employer’s I.D.) at upper right-hand corner. If you do not have one, you must apply to the Internal Revenue Service.

B. Item 1. Insert the exact name of the preferred provider company as it appears on the Articles of Organization or subsequent amendments. Do not use any d/b/a names,

trade names, or abbreviations.

C. Item 2. Insert the full address of the preferred provider company’s principal office, using number and street, city or town, state and zip code.

D. Complete the statement by inserting the name of the treasurer/assistant treasurer completing this form. Date and sign where indicated, and insert title. The officer who

prepares this report must be the one who signs it. In the absence of the treasurer/assistant treasurer, the report may be signed by the president, vice-president, or clerk.

E. Item 3. Insert the last day, month and year of the tax year for which the report is filed.

F. Item 4. Insert the gross receipts or sales as reported on Line 1 of Schedule A of Internal Revenue Service Form 1120-PC.

G. Item 5. Insert the amount of income taxable in Massachusetts as reported on Item 17 of Form 63-23P.

H. Item 6. Insert the total Massachusetts excise or tax due as reported on Item 36 of Form 63-23P.

I. Item 7. Insert the amount of each tax credit taken against the excise imposed by Massachusetts General Laws, Chaper 63 as reported on Form 63-23P.

tdrppc 11/10/16