Installment Tax Report Form - Calendar Year 2007
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1DEPARTMENT OF INSURANCE
Reset
STATE OF ARIZONA
INSTALLMENT TAX REPORT
Financial Affairs Division – Tax Unit
th
CALENDAR YEAR 2007
2910 North 44
Street Suite 210
Phoenix, Arizona 85018-7269
Phone: (602) 364-3998 Fax: (602) 364-3989
Complete Company Name
PRINT/TYPE Preparer’s Name and Title
NAIC Number
State of Incorporation Toll free or collect phone number Fax number
E-Mail Address
1.
Enter the amount reported as “Net Tax Amount (2007 Installment Tax Base)”
From the 2006 Annual Tax and Fees Report ................................................................................................................... $
2.
Is the amount reported on line 1 less than $2,000?
YES - You are not required to pay Installment taxes or file this form.
Please DISCARD this form.
NO - Complete and file this form and pay the total amount due on line 7.
THE DEPARTMENT WILL NOTIFY THE PREPARER OF THIS REPORT IF THERE IS A DISCREPANCY WITH THE INSTALLMENT BASE AMOUNT OR IF AN AUDIT
OF THE 2006 ANNUAL TAX REPORT RESULTS IN A CHANGE TO THE INSTALLMENT BASE AMOUNT.
0.00
IF RESPONSE IN LINE 2 IS NO…..Enter the result of 15% (0.15) times the amount on line 1
3.
..................$
«
4.
Please complete the following table for all modes of payment (Check or ACH) TO SPECIFY THE PAYMENT(S) BEING MADE WITH THIS REPORT ONLY. The
Company may remit each Installment tax payment individually (by or before each applicable due date) or remit a singular amount for two or more Installment tax
payments.
PAYMENT
TAX
WRITE AN “X” IN THE BOX THAT CORRESPONDS TO THE PAYMENT(S)
PAY
LINE
DUE DATES
YOU ARE REMITTING FOR THIS INSTALLMENT TAX REPORT
CODE
4a
3/15/07
If “X”, enter the amount from line 3 here : $______________________
19
4b
4/15/07
If “X”, enter the amount from line 3 here : $______________________
20
4c
If “X”, enter the amount from line 3 here : $______________________
21
5/15/07
4d
6/15/07
If “X”, enter the amount from line 3 here : $______________________
22
4e
7/15/07
If “X”, enter the amount from line 3 here : $______________________
23
4f
If “X”, enter the amount from line 3 here :$______________________
24
8/15/07
0.00
LINE 4. TOTAL INSTALLMENT PAYMENTS (4a + 4b + 4c + 4d + 4e + 4f) FOR THIS REPORT: $
5.
If applicable, complete the following table for all modes of payment (Check or ACH). A payment by check must be mailed, or an ACH payment must post to the
Department’s ACH account, on or before the due date. Use this table to calculate the civil penalty amount to be included [pursuant to A.R.S. § 20-225(A)] with a late
Installment tax payment.
PAYMENT
ONLY ENTER INFORMATION FOR INSTALLMENT TAX PAYMENTS THAT ARE MAILED OR POSTED TO
LINE
THE DEPARTMENT’S ACH ACCOUNT AFTER THE DUE DATE(S) SHOWN IN 4a THROUGH 4f
5a
Enter larger of $25 or 5% of payment line 4a
:
$____________________
5b
Enter larger of $25 or 5% of payment line 4b
:
$____________________
5c
Enter larger of $25 or 5% of payment line 4c
:
$____________________
5d
Enter larger of $25 or 5% of payment line 4d
:
$____________________
5e
Enter larger of $25 or 5% of payment line 4e
:
$____________________
5f
Enter larger of $25 or 5% of payment line 4f
:
$____________________
0.00
LINE 5. TOTAL CIVIL PENALTIES (5a + 5b + 5c + 5d + 5e + 5f) INCLUDED FOR THIS REPORT: $
[26]
6.
If applicable, complete the following table for all modes of payment (Check or ACH). A payment by check must be mailed, or an ACH payment must post to the
Department’s ACH account, on or before the due date. Use this table to calculate the interest amount to be included [pursuant to A.R.S. § 20-225(A)] with a late
Installment tax payment.
PAYMENT
ONLY ENTER INFORMATION FOR INSTALLMENT TAX PAYMENTS THAT ARE MAILED OR POSTED TO
LINE
THE DEPARTMENT’S ACH ACCOUNT AFTER THE DUE DATE(S0 SHOWN IN 4a THROUGH 4f
0.00
0.00
6a
Line 4a amount $___________________ X 0.01 X number of full/partial months late ____: $_____________
0.00
0.00
6b
Line 4b amount $___________________ X 0.01 X number of full/partial months late ____: $_____________
0.00
0.00
6c
Line 4c amount $___________________ X 0.01 X number of full/partial months late ____: $_____________
0.00
0.00
6d
Line 4d amount $___________________ X 0.01 X number of full/partial months late ____: $_____________
0.00
0.00
6e
Line 4e amount $___________________ X 0.01 X number of full/partial months late ____: $_____________
0.00
0.00
6f
Line 4f amount $___________________ X 0.01 X number of full/partial months late ____: $_____________
0.00
LINE 6. TOTAL INTEREST (6a + 6b + 6c + 6d + 6e + 6f) INCLUDED FOR THIS REPORT: $
[26]
0.00
7.
TOTAL PAYMENT AMOUNT
SUM OF TOTAL AMOUNTS ENTERED IN LINES 4, 5 AND 6 : $
CHECK ONLY ONE BOX AND PROVIDE INFORMATION FOR THE SELECTED PAYMENT OPTION:
Check #
payable to the Arizona Department of Insurance for the amount shown on Line 7 is enclosed.
Payment in the amount shown on Line 7 will be sent via ACH delivery in the required format and content (see Form E-ACH.INSTRUCTION).
E-INSTALLMENT TAX (12/06)
P
1
1
AGE
OF
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