Form Mdca - Medical Device Credit Application - 2014

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2014
Form MDCA
Medical Device
Credit Application
Massachusetts
Department of
Revenue
For calendar year 2014 or taxable year beginning
and ending
Medical device company name
Federal Identification or Social Security number
Mailing address
City/Town
State
Zip
Name of contact person
Telephone
E-mail address
1 Type of medical device company:
Corporation 
Trust 
Partnership 
Sole proprietorship 
LLC 
Other
2 Qualified user fees paid to U.S. Food and Drug Administration during the taxable year. (“Qualified user fees” are “user fees” as defined in TIR 06-22.)
Note: Include only those qualified user fees related to new medical devices or to upgrades, changes or enhancements to existing medical devices,
developed or manufactured in Massachusetts. A new medical device or an upgrade, change or enhancement to an existing medical device is “developed
or manufactured in Massachusetts” if more than 50% of the development or manufacturing costs associated with the
medical device or the upgrade, change or enhancement are incurred in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Date(s) of qualified user fee payment(s)
4 Address of Massachusetts plant or facility
5 Brief description of medical device(s) to which the user fees above relate
6 Percentage of development or manufacturing costs incurred in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Note: Attach copies of all USDA Department of Health and Human Services Food and Drug Administration Medical Device User Fee Cover Sheets asso -
ciated with this application.
I declare under the pains and penalties of perjury that to the best of my knowledge, the information contained herein is accurate and complete.
Signature
Date
Mail to: Massachusetts Department of Revenue, Audit Division, 200 Arlington Street, Room 4300, Chelsea, MA 02150, attn.: Medical Device Unit.

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