Form Hcp-Est - Health Care Provider Tax Estimate Payment Voucher Form printable pdf download

Form Hcp-Est - Health Care Provider Tax Estimate Payment Voucher Form

HCP-Est

Maine Revenue Sevices

Health Care Provider Tax

Estimate Payment Voucher

*0514800*

Fiscal Year

Registration No.

Due Date

1. Entity Information

Any change in ownership, address or name should be addressed in correspondence and attached to this voucher.

Section 1:

Complete this section only for the initial return and at the beginning of each ﬁ scal year.

Check one only

We elect to estimate our tax liability based on net operating revenue for the current state ﬁ scal year.

We elect to estimate our tax liability based on a ﬁ scal year where the taxable revenues have been

ﬁ nally determined and are no longer open to audit adjustment.

Year

Month

If the second option is used, the ﬁ nalized period’s ﬁ scal year began

Section 2:

Monthly estimated payment due for month of

Less: Prior Credit (if any)

Total Remittance with return (line 1 less line 2; if less than zero, enter zero

Mail To:



Maine Revenue Service

P.O. Box 9119

Augusta, ME 04332-9119

Print Name

Phone #

Date

Signature and Title

HCP-1 Revised 1/05

Form Hcp-Est - Health Care Provider Tax Estimate Payment Voucher Form