Premium Tax Report Surplus Lines Broker Form - South Dakota Division Of Insurance (Page 2 of 2) in pdf

Premium Tax Report Surplus Lines Broker Form - South Dakota Division Of Insurance Page 2

QUARTERLY REPORT -- SDCL 58-32-44: “If in any PRIOR calendar year a surplus lines broker

collects and remits in excess of five thousand dollars ($5,000.00) of surplus lines premium tax, he/she

shall in the FOLLOWING year remit the tax on a quarterly basis.”

Date

Check

Amount

Quarter

Due

Date

Number

Paid

First

4/30

_________

___________

_____________

Second

7/31

_________

___________

_____________

Third

10/31

_________

___________

_____________

Fourth

1/31

_________

___________

_____________

Sub-Total of Quarterly Payments:

(7) $_____________________

Deduct Credits Due (Attach Itemized List or Explanation): (8) $_____________________

Total: (Line 6 less Line 7 less Line 8)

(9) $_____________________

Add ** Interest, Fines, Penalties Due (if Any):

(10) $_____________________

Total Amount Due: (Line 9 plus Line 10)

(11) $_____________________

**All taxes and installments paid after the Date Due must include a penalty fee of one and one-

half percent (1.5%) per month, or fraction thereof, on the unpaid balance. [SDCL 10-44-16].

BOND #___________________________ EXPIRATION DATE OF BOND:_____________________

COMPANY WRITING BOND:__________________________________________________________

I certify that the above information is true and correct.

_______________________________________________

________________________________

(Broker’s Signature)

(Date)

Premium Tax Report Surplus Lines Broker Form - South Dakota Division Of Insurance Page 2

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