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Form Iip-A - Annual Industrial Insurance (Workers Compensation) Premium Tax Return - 2012

Nevada Department of Taxation

Due Date

______________

Taxpayer ID No:

1550 College Parkway Ste 115

Federal ID: ______________________

March 15, 2013

Carson City, NV 89706

Premium Tax: ______________________

Phone: (775) 684-2000

Retaliatory Tax: ______________________

Fax: (775) 684-2020

Total Remittance: ______________________

ANNUAL INDUSTRIAL INSURANCE (WORKERS COMPENSATION)

PREMIUM TAX RETURN 2012

Department Use Only

Amount: _____________________________

Check No: _____________________________

Date Rec’d: _____________________________

Initials: _____________________________

Net Quarterly Taxable Premiums/Considerations

1. Total Industrial Insurance Premiums - Must agree with Schedule 1, Line 3A

2. Gross Industrial Insurance Premium Tax (3.5% of Line 1 – Must agree with Schedule 1, Line 4 A)

3. Industrial Insurance Credit (Division of Industrial Relations) (NRS 680B.036)

A. Subtotal (Line 2 minus Line 3)

4a.

Home Office Credit, if qualified (NRS 680B.050) 50% or .5 of Line 4 (Form PT-04 and required documents must be attached)

4a.

4b. Amount of Ad Valorem Taxes Paid, if qualified for Home Office Credit (NRS 680B.050)

4b.

4c. Max Credit Allowed

4c.

4d. Allowable Home Office Credits

4d.

5. Subtotal of Net Industrial Insurance Premium Tax Due (Line A minus Line 4d)

6. Property/Casualty Guaranty Association Credit (NRS 687A)

B. Total Overpayments applied from previous years

C. Total Overpayments refunded by Nevada in 2011

7. Net Industrial Insurance Premium Tax Due (Line 5 minus Lines 6 and B, Plus Line C)

8. Penalty ( See Instructions for rate)

9. Daily Interest. Premium Tax Due (Line 7) multiplied by .00049315068 times the number of days late

10. Total Industrial Insurance Premium Tax Due (Line 7 plus Lines 8 and 9)

10.

If Line 10 results in an overpayment, the overpayment may be refunded.

Amount to be refunded

NRS REQUIRES THIS RETURN MUST BE SIGNED

I hereby declare under penalty of perjury that this premium tax report (including any accompanying schedules and statements) has been

examined by me and is true, correct and complete report.

Signature of Taxpayer or Authorized Agent

Printed Name of Taxpayer or Authorized Agent

Date

Telephone

IIP-A

Revised 11-22-11

Form Iip-A - Annual Industrial Insurance (Workers Compensation) Premium Tax Return - 2012

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