Form WV/HCP-3a "Annual Return of Broad Based Health Care Related Taxes" - West Virginia

What Is Form WV/HCP-3a?

This is a legal form that was released by the West Virginia State Tax Department - a government authority operating within West Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the West Virginia State Tax Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form WV/HCP-3a by clicking the link below or browse more documents and templates provided by the West Virginia State Tax Department.

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Download Form WV/HCP-3a "Annual Return of Broad Based Health Care Related Taxes" - West Virginia

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STATE OF WEST VIRGINIA
State Tax Department, Tax Account Administration Div
P.O. Box 773
Charleston, WV 25323-0773
_____________________________________________________________
WYOMING NURSING & REHABILITATION CE
Letter Id:
L1756938240
Name
240 CAPITOL ST STE 500
Issued:
08/22/2017
Account #: ________________
_____________________________________________________________
CHARLESTON WV 25301-2297
Account #:
2215-7124
Address
Period:
12/31/2017
_____________________________________________________________
City
State
Zip
H0
40
ANNUAL RETURN OF BROAD BASED HEALTH CARE RELATED TAXES
WV/HCP-3A
RTNHCB
rtL338 v.1
Period Ending:
Due Date:
Extension Date:
M
M
D
D
Y
Y
Y
Y
Method of Accounting
ACCRUAL
CASH
FINAL
AMENDED
(Check One)
COMPUTATION OF TAX
1.
Total Annual Tax Due from Schedule A Line 7
.
2.
Total Estimated Payments for the Period Covered by this Return
.
3.
Credit for Overpayment from Prior Year Annual Return
.
4.
Total Payments and Credits (Add Lines 2 and 3)
.
5.
Total Tax Due (Line 1 minus Line 4 - If Line 4 is Greater than Line 1, Enter 0)
.
6. Overpayment Amount (Line 4 minus Line 1 - If Line 1 is Greater than Line 4, Enter 0)
.
7. Amount of Line 6 to be Credited to Next Year's Tax
.
8. Amount of Line 6 to be Refunded (Line 6 minus Line 7)
.
Under penalties of perjury, I declare that I have examined this return (including accompanying schedules and statements) and to the best of my knowledge and
belief it is true, and complete.
(Signature of Taxpayer)
(Name of Taxpayer - Type or Print)
(Title)
(Date)
(Person to Contact Concerning this Return)
(Telephone Number)
(E-mail Address)
(Signature of preparer other than taxpayer)
(Address)
(Date)
MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT
Tax Account Administration Div
P.O. Box 773, Charleston, WV 25323-0773
FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297
For more information visit our web site at: www.tax.wv.gov
File online at https://mytaxes.wvtax.gov
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0
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STATE OF WEST VIRGINIA
State Tax Department, Tax Account Administration Div
P.O. Box 773
Charleston, WV 25323-0773
_____________________________________________________________
WYOMING NURSING & REHABILITATION CE
Letter Id:
L1756938240
Name
240 CAPITOL ST STE 500
Issued:
08/22/2017
Account #: ________________
_____________________________________________________________
CHARLESTON WV 25301-2297
Account #:
2215-7124
Address
Period:
12/31/2017
_____________________________________________________________
City
State
Zip
H0
40
ANNUAL RETURN OF BROAD BASED HEALTH CARE RELATED TAXES
WV/HCP-3A
RTNHCB
rtL338 v.1
Period Ending:
Due Date:
Extension Date:
M
M
D
D
Y
Y
Y
Y
Method of Accounting
ACCRUAL
CASH
FINAL
AMENDED
(Check One)
COMPUTATION OF TAX
1.
Total Annual Tax Due from Schedule A Line 7
.
2.
Total Estimated Payments for the Period Covered by this Return
.
3.
Credit for Overpayment from Prior Year Annual Return
.
4.
Total Payments and Credits (Add Lines 2 and 3)
.
5.
Total Tax Due (Line 1 minus Line 4 - If Line 4 is Greater than Line 1, Enter 0)
.
6. Overpayment Amount (Line 4 minus Line 1 - If Line 1 is Greater than Line 4, Enter 0)
.
7. Amount of Line 6 to be Credited to Next Year's Tax
.
8. Amount of Line 6 to be Refunded (Line 6 minus Line 7)
.
Under penalties of perjury, I declare that I have examined this return (including accompanying schedules and statements) and to the best of my knowledge and
belief it is true, and complete.
(Signature of Taxpayer)
(Name of Taxpayer - Type or Print)
(Title)
(Date)
(Person to Contact Concerning this Return)
(Telephone Number)
(E-mail Address)
(Signature of preparer other than taxpayer)
(Address)
(Date)
MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT
Tax Account Administration Div
P.O. Box 773, Charleston, WV 25323-0773
FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297
For more information visit our web site at: www.tax.wv.gov
File online at https://mytaxes.wvtax.gov
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ANNUAL RETURN OF BROAD BASED HEALTH CARE RELATED TAXES
WV/HCP-3A
Account #: _______________
rtL338 v.1
SCHEDULE A - COMPUTATION OF TAX FOR TAXABLE YEAR ____________ THRU ____________
LINE
TAXABLE
COL 1
COL 2
COL 3
COL 4
COL 5
COL 6
CODE
SERVICE
TOTAL GROSS
BAD DEBT
CONTRACTUAL
TAXABLE GROSS
RATE
TAX DUE
PROCEEDS
ALLOWANCES
PROCEEDS
COL 4 X COL 5
COL 1 - COL 2 & 3
Ambulatory
0.0175
1
.
.
.
.
.
Surgical
Independent
0.05
2
Lab/X-Ray
.
.
.
.
.
Inpatient
0.025
3
Hospital
.
.
.
.
.
Intermediate Care
0.055
4
.
.
.
.
.
Facility/MR
0.055
5
Nursing Facility
.
.
.
.
Outpatient
0.025
6
.
.
.
.
.
Hospital
SCHEDULE A TOTAL TAX DUE
7
.
(ADD COL 6 FOR ALL TAXABLE SERVICES) ENTER HERE AND ON SCHEDULE 1 LINE 1
INSTRUCTIONS
SCHEDULE A
Report revenue for the full taxable year.
Accrual Basis taxpayers may reduce their Column 1 Total Gross Proceeds by Column 2 Bad Debt and Column 3 Contractual.
Allowance deductions to the extent that they were included in gross receipts upon which the tax imposed was paid.
(Note: Nursing Facility/Nursing Home Service providers may not reduce their Gross Proceeds by Contractual Allowances).
Cash Basis taxpayers may not claim Column 2 Bad Debt and Column 3 Contractual Allowance deductions.
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