Form LQ11_1206 "Nursing Facility Quality Assessment Reporting Form" - Delaware

What Is Form LQ11_1206?

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

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Delaware Department of Finance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form LQ11_1206 by clicking the link below or browse more documents and templates provided by the Delaware Department of Finance.

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Download Form LQ11_1206 "Nursing Facility Quality Assessment Reporting Form" - Delaware

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Rate (4.8 / 5) 36 votes
2018 - 2019
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STATE OF DELAWARE
Department of Finance
NURSING FACILITY
Print Form
Division of Revenue
QUALITY ASSESSMENT
820 N. French Street
REPORTING FORM
P.O. Box 2340
REV CODE 0028-20
Wilmington, DE 19899-2340
FORM LQ11_1206
1. Enter Account Number (No Dashes)
408 NURSING FACILITY QUALITY ASSESSMENT FEE
AMENDED
2. Business Code Group Description
08-31-18
3. Tax Period Ending Date
Due on or Before
10-30-18
4. Facility Name
5. Facility Location Address
6. Mailing Address if Different
City
City
State
Zip Code
State
Zip Code
Is your nursing facility required to file this return?
YES
NO
A. During the entire calendar quarter, did the facility exclusively serve children?..................................................................
YES
NO
B. During the entire calendar quarter, was the number of licensed nursing home beds less than 47?.................................
C. If nursing services and assisted/independent living services are provided on the same campus, are the number of
YES
NO
assisted/independent living beds at least twice (2 times) the number of nursing beds?..................................................
If the answer is “yes” to any of the above questions, the facility is exempt from this tax.
TOTAL/AVERAGE
Jun
Jul
Aug
1. Number of annual Medicaid patient days (from most recently filled Medicaid Cost Report)
2. Number of licensed nursing home beds (see “B” above)
0
3. Number of assisted/independent living beds on same campus (see “C” above)
0
4. Number of nursing facility resident days
0
5. Number of Medicare resident days
0
6. Number of non-Medicare resident days (Line 4 minus Line 5)
0
7. If Line 1 is less than 44,000, enter $30.15; if 44,000 or greater, enter $15.98
30.15
$
8. TOTAL AMOUNT DUE (Line 6 times Line 7)
0.00
$
9. TOTAL AMOUNT REMITTED
I declare under penalties as provided by the law that the information on this application is true, correct and complete.
DATE
PRINT NAME / TITLE
SIGNATURE
*DF80017019999*
(Revised 04/2018)
DF80017019999
2018 - 2019
Reset
STATE OF DELAWARE
Department of Finance
NURSING FACILITY
Print Form
Division of Revenue
QUALITY ASSESSMENT
820 N. French Street
REPORTING FORM
P.O. Box 2340
REV CODE 0028-20
Wilmington, DE 19899-2340
FORM LQ11_1206
1. Enter Account Number (No Dashes)
408 NURSING FACILITY QUALITY ASSESSMENT FEE
AMENDED
2. Business Code Group Description
08-31-18
3. Tax Period Ending Date
Due on or Before
10-30-18
4. Facility Name
5. Facility Location Address
6. Mailing Address if Different
City
City
State
Zip Code
State
Zip Code
Is your nursing facility required to file this return?
YES
NO
A. During the entire calendar quarter, did the facility exclusively serve children?..................................................................
YES
NO
B. During the entire calendar quarter, was the number of licensed nursing home beds less than 47?.................................
C. If nursing services and assisted/independent living services are provided on the same campus, are the number of
YES
NO
assisted/independent living beds at least twice (2 times) the number of nursing beds?..................................................
If the answer is “yes” to any of the above questions, the facility is exempt from this tax.
TOTAL/AVERAGE
Jun
Jul
Aug
1. Number of annual Medicaid patient days (from most recently filled Medicaid Cost Report)
2. Number of licensed nursing home beds (see “B” above)
0
3. Number of assisted/independent living beds on same campus (see “C” above)
0
4. Number of nursing facility resident days
0
5. Number of Medicare resident days
0
6. Number of non-Medicare resident days (Line 4 minus Line 5)
0
7. If Line 1 is less than 44,000, enter $30.15; if 44,000 or greater, enter $15.98
30.15
$
8. TOTAL AMOUNT DUE (Line 6 times Line 7)
0.00
$
9. TOTAL AMOUNT REMITTED
I declare under penalties as provided by the law that the information on this application is true, correct and complete.
DATE
PRINT NAME / TITLE
SIGNATURE
*DF80017019999*
(Revised 04/2018)
DF80017019999