2006 Annual Tax And Fees Report Form (Foreign And Alien Fraternal Benefit Society) Page 3
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1
2
3COMPANY NAME
NAIC NO.
Total Arizona Premiums
includes policy membership, other fees and all other considerations for insurance from all classes of insurance whether
designated as a premium or otherwise received on account of policies and contracts after deducting applicable cancellations, returned premiums, policy
dividends, refunds, savings coupons and other similar returns paid or credited to policyholders and not reapplied as premiums for new, additional or extended
insurance.
PART A - 2006 RETALIATORY TAX COMPUTATION
I
!
MPORTANT
E
P
S
I
,
“
”
T
R
NTER
REMIUM AMOUNTS IN BOTH COLUMNS AND IF EXEMPT FROM TAX IN THE
TATE OF
NCORPORATION
ENTER
O
IN THE
AX
ATE LINES FOR
C
A. A
A
B
P
2006 A
S
,
OLUMN
TTACH A COPY OF
RIZONA
USINESS
AGE FROM THE
NNUAL
TATEMENT
EVEN IF PREMIUMS ARE NOT TAXABLE
In the State of Incorporation Column, enter the tax computations for a like Arizona insurer doing business in your state of incorporation, using the Arizona premiums as the base
amount for taxes imposed. In the Arizona column, enter only the Arizona premiums written.
State of
Incorporation
Arizona
( A )
( B )
FL gross
1.
Total Arizona Life Premiums
$
$
FL tax = 0
Less Deductions:
a) Paid in cash or left on deposit
(-)
b) Applied to pay renewal premiums (ONLY if included in line 1 above)
(-)
c) Other (SPECIFY)
(-)
0.00
2.
Net Taxable Life Premiums (line 1 minus 1a, 1b, and 1c)
$
3.
0.00%
Life Premium Tax Rate
E
XEMPT
4.
0.00
0.00
Life Tax Due
$
$
FA gross
5.
Total Arizona Annuity Considerations
$
$
FA Tax = 0
Less Deductions (SPECIFY)
(-)
a)
b)
(-)
6.
0.00
Net Taxable Annuity Considerations (line 5 minus 5a and 5b)
$
7.
0.00%
Annuity Consideration Tax Rate
E
XEMPT
0.00
8.
0.00
Annuity Tax Due
$
$
FAH gross
9.
Total Arizona Accident and Health Premiums
$
$
FAH Tax = 0
Less Deductions (SPECIFY)
a)
(-)
b)
(-)
10.
0.00
Net Taxable Accident & Health Premiums (9 minus 9a and 9b)
$
0.00%
11.
Accident & Health Tax Rate
E
XEMPT
12.
0.00
0.00
Accident & Health Premium Tax Due
$
$
13.
0.00
330.00
Retaliatory Worksheet Totals (Page 2, line 17)
$
$
14.
0.00
330.00
Add lines 4, 8, 12, and 13
$
$
(DOM)
330.00
15.
Total of Arizona column, line 14
$
CANNOT BE
Retaliatory Tax Due (column A, line 14 minus
0.00
16.
NEGATIVE
line 15. If result is less than “0”, enter “0”)
Carry to Page 1, Part B, line 1
$
←
(RT gross/tax)
IMPORTANT NOTE: THE RETALIATORY AMOUNT DUE MAY NOT BE OFFSET IN ANY MANNER
E-FRATERNAL (R
. 12/06)
STATE OF ARIZONA
P
3
3
EV
AGE
OF
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