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Form Iip-A - Annual Industrial Insurance (Workers Compensation) Premium Tax Return - 2012 Page 4

Line 7 Net Premium Tax Due. Enter the amount of Net Premium Tax due. Line 5 minus Lines 6 and B, plus Line C.

Line 8 Penalty If this return is not submitted/postmarked and taxes are not paid on or before the due date as shown on the face of

this return, the amount of penalty due is a) For returns with Period(s) Ending prior to and including 3/31/07 the Penalty is 10%; b) For

returns with Period(s) ending 4/30/07 and after; the amount of penalty due is based on the number of days the payment is late per

NAC 360.395 (see table below). The maximum penalty is 10%.

Number of days late

Penalty Percentage

Multiply by:

1 - 10

0.02

11 - 15

0.04

16 - 20

0.06

21- 30

0.08

31 +

10%

0.10

Determine the number of days late the payment is, and multiply the net tax owed (Line 7) by the appropriate rate based on the table

above. The result is the amount of penalty that should be entered. For Example, the taxes were due January 31, but not paid until

February 15 so the penalty is 4%.

Line 9 Daily Interest If this return will not be postmarked and the taxes paid on or before the due date as shown on the face of this

return, interest will be calculated daily. Line 7 multiplied by .00049315068 times the number of days late.

Line 10 Total Adjusted Premium Tax Due If the calculated amount entered on this line results in a negative figure, this may

refunded. Pursuant to NRS 680B.120 request for refund must be made within 1 year after the date such fees, charges or taxes were

originally required to be paid or within 30 days after the date of payment of any additional tax, charge or fee. If premium taxes and/or

retaliatory assessment are due, make check payable to the Department of Taxation.

IIP-A

Revised 11-22-11

Form Iip-A - Annual Industrial Insurance (Workers Compensation) Premium Tax Return - 2012 Page 4