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MONTANA Form ICFUF Rev. 4-05 Intermediate Care Facility Utilization Fee Quarter ending _____/_____/_____ Federal ID #__________________ Name and address of intermediate care facility _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 1. Total facility expenditures for quarter .......................... $_______________ 2. Line 1 times 6% (.06) .................................................. $_______________ 3. Total number of resident bed days for quarter ............ ________________ 4. Utilization fee per resident bed day (line 2 divided by line 3) .............................................. $_______________ 5. Total utilization fee due (line 3 times line 4) ..................................................... $_______________ 6. Penalty and interest ........................................................................................ $_______________ 7. Total paid with return ....................................................................................... $_______________ ________________________________________ _________________ ________________ Signature of preparer Date Phone Retain a copy for your records. Statement and remittance for any tax due must be received on or before the last day of the month following the end of each calendar quarter. If you have an ques- tions, please call or write to: Montana Department of Revenue PO Box 5835 Helena, MT 59604-5835 (406) 444-6900 345

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gov revenue formsandresources forms 05-ICFUF

  • 1. MONTANA Form ICFUF Rev. 4-05 Intermediate Care Facility Utilization Fee Quarter ending _____/_____/_____ Federal ID #__________________ Name and address of intermediate care facility _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 1. Total facility expenditures for quarter .......................... $_______________ 2. Line 1 times 6% (.06) .................................................. $_______________ 3. Total number of resident bed days for quarter ............ ________________ 4. Utilization fee per resident bed day (line 2 divided by line 3) .............................................. $_______________ 5. Total utilization fee due (line 3 times line 4) ..................................................... $_______________ 6. Penalty and interest ........................................................................................ $_______________ 7. Total paid with return ....................................................................................... $_______________ ________________________________________ _________________ ________________ Signature of preparer Date Phone Retain a copy for your records. Statement and remittance for any tax due must be received on or before the last day of the month following the end of each calendar quarter. If you have an ques- tions, please call or write to: Montana Department of Revenue PO Box 5835 Helena, MT 59604-5835 (406) 444-6900 345