What does Schedule A calculate?

It calculates the low-income portion of a Relevant Hospital Entity’s unreimbursed costs and directs the user to enter the result on Form PTAX-300-H, Line 17.

Who uses this schedule?

A Relevant Hospital Entity uses Schedule A when completing Form PTAX-300-H. The schedule asks for costs, gross charges, and calculations used to determine a low-income ratio.

Do I need a notary for Schedule A?

No. The schedule has no notary block or sworn attachment instructions, and it does not state that the signer must sign or date it.

How do I submit Schedule A?

Attach Schedule A to Form PTAX-300-H as the schedule instructs. It does not identify a submission office or method; check the county website for current contact details.

Rock Island County, IL · Rock Island County

No notary required

Schedule A Calculation of Low-Income Portion of Unreimbursed Costs

This calculation schedule is completed by a Relevant Hospital Entity and attached to Form PTAX-300-H to calculate the low-income portion of unreimbursed costs.

At a glance

Issued by: City of Rock Island County · Rock Island County, Rock Island County, Illinois
Notarization: Not required: file this form without a notary.
Official source: rockislandcountyil.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

Schedule A calculates the low-income portion of a Relevant Hospital Entity’s unreimbursed costs for entry on Form PTAX-300-H, Line 17. The schedule totals costs for services and activities, including emergency care, medical education, and research, then calculates a low-income ratio using specified charges and a cost-to-charge ratio. It is completed when preparing Form PTAX-300-H and attached to that form.

Who needs it

A Relevant Hospital Entity completing Form PTAX-300-H uses this schedule to calculate the low-income portion of its unreimbursed costs.

How to submit it

The schedule says to attach it to Form PTAX-300-H but does not identify a submission office or method. Submit it to the county department named on the form; check the county website for current contact details.

About notarization

This schedule has no notary block or sworn attachment instructions; it provides calculation lines and does not state that the signer must sign or date it.

How to submit this form

1
Download the Schedule
Download Schedule A for calculating the low-income portion of unreimbursed costs.
2
Complete the Cost Calculations
Enter the unreimbursed costs, charges, cost-to-charge ratios, and calculations requested in Steps 1 through 3.
3
Attach the Schedule
Attach the completed Schedule A to Form PTAX-300-H, as directed on the schedule.
4
Submit the Form
The schedule does not give submission details. Check the county website for current contact information.

Frequently asked questions

What does Schedule A calculate?: It calculates the low-income portion of a Relevant Hospital Entity’s unreimbursed costs and directs the user to enter the result on Form PTAX-300-H, Line 17.
Who uses this schedule?: A Relevant Hospital Entity uses Schedule A when completing Form PTAX-300-H. The schedule asks for costs, gross charges, and calculations used to determine a low-income ratio.
Do I need a notary for Schedule A?: No. The schedule has no notary block or sworn attachment instructions, and it does not state that the signer must sign or date it.
How do I submit Schedule A?: Attach Schedule A to Form PTAX-300-H as the schedule instructs. It does not identify a submission office or method; check the county website for current contact details.

Need something notarized?

This Schedule A Calculation of Low-Income Portion of Unreimbursed Costs doesn’t need a notary, but Illinois residents can notarize other documents online with a commissioned online notary.