Form Act-1 - West Virginia Acute Care Hospital Tax
Download a blank fillable Form Act-1 - West Virginia Acute Care Hospital Tax in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Act-1 - West Virginia Acute Care Hospital Tax with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Form
West Virginia
West Virginia
ACT-1
State Tax
Acute Care Hospital Tax
Orig. 05-13
Department
**Please read instructions on the next page before completing this form.**
Account
Amended Return
Number
SEE INSTRUCTIONS
Period
Due
ON PAGE 2
Ended
Date
Taxpayer Name
Address
City
State
Zip
Tax Due
(Multiply Gross Receipts by Tax Rate)
Tax Rate
Gross Receipts
.0045
1. Inpatient Hospital Services....................
.0045
2. Outpatient Hospital Services.................
3. Tax Due (add lines 1 & 2)..................................................................................................
$
4. Total Amount Remitted with this Return...........................
Under penalties of perjury, I declare that I have examined this return, accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct and complete.
Signature of Officer/Partner or Member
Print name of Officer/Partner or member
Title
Date
Business Telephone Number
Paid preparer’s signature
Firm’s name and address
Date
Preparer’s Telephone Number
MAIL TO:
WEST VIRGINIA STATE TAX DEPARTMENT
TAX ACCOUNT ADMINISTRATION DIVISION
PO BOX 773
CHARLESTON, WV 25323-0773
*h08201201a*
Form ACT-1
Page 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial