The Montana ICFUF (Intermediate Care Facility Utilization Fee) form is used by facilities that provide intermediate care services to report the applicable utilization fee. This fee is based on the total facility expenditures and the number of resident bed days during each calendar quarter.
How to Complete the ICFUF Form
1. General Information
- Quarter Ending Date:
Enter the end date of the quarter for which you are filing the utilization fee (e.g., March 31, June 30, etc.). - Federal ID Number:
Provide the Federal Employer Identification Number (FEIN) of the facility. - Facility Name and Address:
Enter the name and full address of the Intermediate Care Facility.
2. Section 1: Calculation of Utilization Fee
- Line 1 – Total Facility Expenditures for the Quarter:
Enter the total expenditures for the facility for the quarter. This includes all allowable expenses related to the operation of the intermediate care facility. - Line 2 – Total Facility Expenditures Times 6% (0.06):
Multiply the amount in Line 1 by 6% (0.06). This represents the utilization fee rate applied to the total facility expenditures. - Line 3 – Total Number of Resident Bed Days for the Quarter:
Enter the total number of bed days during the quarter. This is the sum of all the days that beds in the facility were occupied by residents. - Line 4 – Utilization Fee Per Resident Bed Day:
Divide the value in Line 2 by the value in Line 3 to calculate the utilization fee per resident bed day. - Line 5 – Total Utilization Fee Due:
Multiply the value in Line 3 (total number of resident bed days) by the value in Line 4 (utilization fee per resident bed day). This gives the total utilization fee due.
3. Penalty and Interest
- Line 6 – Penalty and Interest:
If the payment is late, a penalty and interest will apply. You will need to calculate this based on the guidelines provided by the Montana Department of Revenue. The current rate for penalty and interest should be available on the department’s website or by contacting them.
4. Total Payment Due
- Line 7 – Total Paid with Return:
Enter the total amount of the fee and any penalties or interest that you are submitting with the return. This is the amount the facility must pay for the quarter.
Sign and Submit the Form
- Signature of Preparer:
The preparer of the form must sign and date the form. - Phone Number:
Provide the phone number of the person who prepared the form in case of any follow-up questions.
Filing and Payment Deadline
- Retain a Copy:
Retain a copy of the completed form for your records. - Submission Deadline:
The form and any payment due must be received by the Montana Department of Revenue on or before the last day of the month following the end of each calendar quarter.
Mailing Address for Submission
Send the completed form and any payment due to:
Montana Department of Revenue
P.O. Box 5835
Helena, MT 59604-5835
For further assistance, you can contact the Montana Department of Revenue at:
- Phone: (406) 444-6900
- Montana Relay: 711 (for hearing impaired)
- Email: You can reach the department via mail or call for email inquiries.
This form helps ensure that Intermediate Care Facilities comply with the utilization fee requirements in Montana. Be sure to calculate and submit all required amounts by the deadline to avoid penalties.