Form Nfbt - Nursing Facility Bed Tax Quarterly Report Form - Montana Department Of Revenue
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1MONTANA
NFBT
Rev. 4-05
Nursing Facility Bed Tax
Quarterly Report
15-60-101, MCA
Facility ID # _________________________
Quarter ending _________/__________/_________
Federal ID #_________________________
Name and
address
of Nursing
Facility
a.
b.
c.
d.
e.
f.
Bed Days
Bed Days
Bed Days
Bed Days
Bed Days
Bed Days
Available
Occupied
Medicaid
Medicare
Other
Private Pay
1. First Month
2. Second Month
3. Third Month
4. Quarter Total
5. Total bed days subject to tax (Total line 4 column b)
Column b must equal total of Columns c, d, e, and f
6. Total Tax (line 5 X $7.05)
7. Adjustments (explain on back of form)
8. Penalty and interest
9. Total tax remitted (Lines 6 + 7 + 8)
Revenue Account Code
503001
Date
Signature of Preparer
Print Name
Phone No.
Retain a copy for audit purposes. Statement and remittance for any tax due must be received on or before the
30th day following the end of each calendar. If you have any questions, please contact our Customer Service
Center at:
Montana Department of Revenue
P.O. Box 5835
Helena, MT 59604
(406) 444-6900
309
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