This blog post will be discussing the Form Mh 4453, which is a Mortgage Credit Certificate (MCC) form. An MCC is a document that helps homebuyers reduce their federal income taxes. The form can be used by both first-time and repeat homebuyers to claim a tax credit for a portion of the mortgage interest paid on the purchase of their home. In this blog post, we will discuss what the form is, who can use it, and how to fill it out correctly. Stay tuned!
| Question | Answer |
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| Form Name | Form Mh 4453 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ApplicFeesInv tdmh fiscal services form |
Tennessee Department of Mental Health And Substance Abuse Services
Office of Licensure
LICENSURE APPLICATION FEE INVOICE
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INSTRUCTIONS: Use the schedule below to determine the total amount of |
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SEND PAYMENT AND COMPLETED INVOICE TO: |
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fees to be submitted. Do Not Send Cash. Make Check or Money Order |
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TDMHSAS FISCAL SERVICES SECTION |
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payable to: State of Tennessee. |
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601 MAINSTREAM DRIVE |
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PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION |
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NASHVILLE, TN 37243 |
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NAME, MAILING ADDRESS OF PERSON/AGENCY SUBMITTING FEE: |
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APPLICATION DATE |
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NAME |
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ADDRESS |
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TYPE OF LICENSE: |
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CITY |
STATE |
ZIP |
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INITIAL |
RENEWAL |
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NAME AND STREET ADDRESS OF SERVICE(S) AND/OR FACILITY(S) FOR WHICH FEE SUBMITTED: (Use additional pages if needed.) (Copy of Page 2 of Renewal Application acceptable.)
NAME |
Email Address: |
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STREET/RURAL ROUTE |
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RR BOX # |
CITY |
ZIP |
COUNTY |
COMPUTE THE AMOUNT OF TOTAL FEE: |
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No. of Sites Operating One (1) Distinct Category of Services and/or Facility: No. of Sites Operating Two (2) Distinct Categories of Services and/or Facilities: No. of Sites Operating Three (3) Distinct Categories of Services and/or Facilities: No. of Sites Operating Four (4) Distinct Categories of Services and/or Facilities:
No. of Sites Operating More Than Four (4) Distinct Categories of Services and/or Facilities:
x $ |
810.00=….$ |
x $ |
1,010.00=….$ |
x $ |
1,220.00=….$ |
x $ |
1,420.00=….$ |
x $ |
1,620.00=….$ |
Capacity of Two to Three
Fees for Mental Health Hospitals
Total Number of Beds at All Sites
RESIDENTIAL FACILITY FEES
Site(s) x $ 200.00=………………………………………………... $
Site(s) x $ 280.00=…………………………………………………$
Site(s) x $410.00=………………………………………………… $
Site(s) x $ 810.00=………………………………………………. $
Site(s) x $1,220.00=……………………………………………… $
x $175.00 (per bed) =…………………………………………………… $
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GRAND TOTAL OF FEES = $ |
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FOR TDMHSAS OFFICE USE |
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1. FISCAL SERVICES SECTION: |
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2. REGIONAL LICENSURE OFFICE VERIFICATION: |
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Date Fee Rec’d: |
Amnt. Rec’d: $ |
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Date Fee Verified: |
Correct Fee: |
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Receipt Number # |
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Correct. |
Insufficient. |
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Overpayment. |
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Received By: |
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Verified By: |
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Licensure Application Fee Invoice |
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