Form Ipt-R - Annual Insurance Premium Tax Reconciliation Return 2010
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5Tax Identification No: ___
______
Nevada Department of Taxation
Due Date
1550 College Parkway, Rm 115
Federal ID: ______________
March 15, 2011
Carson City, NV 89706-7921
Premium Tax: ______________
Phone: (775) 684-2000
Retaliatory Tax: _______________
Fax: (775-) 684-2020
Total Remittance: _______________
ANNUAL INSURANCE PREMIUM TAX RECONCILIATION RETURN 2010
DO NOT INCUDE INDUSTRIAL INSURANCE (WORKERS COMPENSATION)
Departmental Use Only
Amount: ______________________
Check No: ______________________
PM Date: ______________________
Initials: ______________________
Net Quarterly Taxable Premiums
REPORTED
ACTUAL
1. March 31, 2010
1.
2. June 30, 2010
2.
3. September 2010
3.
4. December 2010
4.
5. Total Premiums/Considerations (Add Lines 1 through 4)
5.
6. Total Premiums/Consideration (Line 5, Column B – Must agree with Schedule 1, Line 6 A)
6.
7. Gross Premium Tax (3.5% of Line 6 or 2% for RRG, if qualified, - Must agree with Schedule 1, Line 12 A)
7.
8a. Home Office Credit, if qualified (NRS 680B.050) 50% or .5 of Line 7
8a.
(Form PT-04 and required documents must be attached)
8b. Amount of Ad Valorem Taxes Paid, if qualified for Home Office Credit (NRS 680B.050)
8b.
8c. Max Credit Allowed (See Instructions)
8c.
8d. Allowable Home Office Credit
8d.
9. Subtotal of Premium Tax due for Calendar Year 2010 (Line 7 minus Line 8d)
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10. Life/Health Guaranty Association Offset (NRS 686 C)
10.
11. Property/Casualty Guaranty Association Credit (NRS 687 A)
11.
12. Total Cash Payments made with Quarterly Returns (Do Not Include Any Penalty and/or Interest)
12.
13. Total Overpayment applied from previous years
13.
14. Total Overpayment refunded by Nevada in 2010
14.
15. Net Premium Tax Due
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16. Penalty (See Instructions for rate)
16.
17. Daily Interest. Premium Tax Due (Line 15) multiplied by .00049315068 times the number of days late
17.
18. Total Premium Tax Due (Line 15 plus Lines 16 and 17)
18.
If Line 18 results in an overpayment, the overpayment will be refunded.
Amount to be refunded
Annuity Election:
Front End:
Date Election Approved by Commissioner: _____________
Back End:
Date Election Approved by Commissioner: _____________
NRS REQUIRES THIS RETURN MUST BE SIGNED
I hearby 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 of Authorized Agent
Date
Telephone
IPT-R
Revised 12/17/10
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