Line 1, Class01—Hospitals—Enter gross revenues received for the provision of hospital services. Multiply the gross revenues entered on line 1 by 2.5 percent. Enter the amount computed on line 1, Amount of Tax. Round gross revenues and tax amounts to the nearest dollar.

Line 2, Class 12—Licensed Home Health Agency Services—Enter the gross receipts for the provision of licensed home health agency services. Multiply the gross receipts by 2 percent and enter the amount on line 2.

Line 3, Class 14—ICF-MR Services—Enter the gross receipts for the provision of ICF-MR services. Multiply the gross receipts by 5.5 percent and enter the amount on line 3.

Line 4, Class 30—Regional Community Mental Health and Mental Retardation Services—Enter the gross receipts for the provision of RCMH-MR services. Multiply the gross receipts by zero (0%) percent and enter the amount on line 4.

Line 5, Class 31—Psychiatric Residential Treatment Facility Services—Enter the gross receipts for the provision of PRTF services. Multiply the gross receipts by zero (0%) percent and enter the amount on line 5.

Line 6, Class 32—Medicaid Managed Care Organization Services—Enter the gross receipts for the provision of MMCO services. Multiply the gross receipts by 5.5 percent and enter the amount on line 6.

Line 7, Class 33—Supports for Community Living Services—Enter the gross receipts for the provision of supports for community living services. Multiply the gross receipts by 5.5 percent and enter the amount on line 7.

Line 8, Class 15—Hospital Based Nursing Facilities—Enter the total amount of non-Medicare patient bed days for the month. Multiply the total non-Medicare patient bed days by $5.63 and enter the amount online 8.

Line 9, Class 77—Non-Hospital Based Nursing Facility Services for those Facilities with a Total Bed Capacity of 60 or Fewer Beds—Enter the total amount of non-Medicare patient bed days for the month. Multiply the total non-Medicare patient bed days by $2.82 and enter the amount on line 9. Facility must contain licensed intermediate care facility beds as of September 1, 2005.

Line 10, Class 88—Non-Hospital Based Nursing Facility Services for those Facilities with Annual Total Census Days Exceeding 60,000—Enter the total amount of non-Medicare patient bed days for the month. Multiply the total non-Medicare patient bed days by $6.38 and enter the amount on line 10.

Line 11, Class 99—Non-Hospital Based Nursing Facility Services for those Facilities with Annual Total Census Days Less than or Equal to 60,000—Enter the total amount of non-Medicare patient bed days for the month. Multiply the total non-Medicare patient bed days by $19.89 and enter the amount on line 11.

Line 12, Tax Due—Add the amount of tax computed on lines 1 through 11.

Line 13, Preauthorized Credits—If you have received a written preauthorized credit memo from the Department of Revenue, indicate the credit memo date in the space provided. Enter only credit amounts previously authorized. If the amount of authorized credit is greater than the Tax Due on line 12, claim only an amount equal to line 12. Any remaining credit may be claimed on the next return filed. Do not use a minus sign, brackets, parentheses or other marks to indicate a credit amount. Line 14, Net Tax Due—Subtract line 13 from line 12. Enter the amount computed on line 14.

Line 14, Net Tax Due—Subtract line 13 from line 12. Enter the amount computed on line 14.

Line 15, Penalties—

Failure to File a Timely Return—2 percent for each 1-day to 30-day period, maximum 20 percent, minimum $10 regardless of the amount of tax due or whether there is any tax due.

Failure to Pay Timely—2 percent for each 1-day to 30-day period, maximum 20 percent, minimum $10.

Both penalties apply if the return is filed late and payment is late. Additional penalties for negligence, failure to file the report or return, fraud, etc., may be assessed in accordance with KRS 131.180 (Uniform Civil Penalty Act). Enter total penalty amount computed online 15.

Line 16, Interest—Any tax not paid on or before the due date of the return (see return due date printed at the top of the return) shall bear interest from the date due until the date of payment. The current daily interest rate is listed on line 16 of the original return. Compute the interest as follows: (number of days late) x (daily interest rate) x (net tax due, line 12). Enter the amount computed on line 16.

Line 17, Total Amount Due—Add amounts on lines 14, 15 and 16, and enter on line 17. You must pay the amount shown due on line 17. Make a check payable to Kentucky State Treasurer and enclose it with the return. On the face of the check, write “Provider Tax” and your Health Care Provider Account Number. Do not staple the check to the return.

Signature—Each return must be signed and dated by the president, or other principal officer, partner or proprietor. Also, the return must be signed by the preparer if different.

Return and Payment Due Date—The return, with payment included, must be postmarked no later than the 20th day of the next succeeding calendar month following the close of the taxable period.

Officer Liability—The president, vice-president, secretary, treasurer or any other person holding an equivalent corporate office of any corporation subject to the Kentucky health care provider tax shall be personally and individually liable, both jointly and severally, for the taxes imposed by KRS Chapter 142. No person will be personally or individually liable if that person did not have authority in the management of the business or financial affairs of the corporation at the time the taxes become or became due. Taxes shall include interest accrued and all applicable penalties and fees.

Per KRS 142.341, providers must keep records for not less than six years.