Form Ipt-A - Annual Insurance Premium Tax Return 2010
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5Nevada Department of Taxation
Due Date
Tax Identification No: _______________________
1550 College Parkway, Rm 115
Federal ID: _______________________
Carson City, NV 89706-7921
Premium Tax: _______________________
March 15, 2011
Phone: (775) 684-2000
Retaliatory Tax: _______________________
Fax: (775) 684-2020
Total Remittance: _______________________
ANNUAL INSURANCE PREMIUM TAX RETURN 2010
DO NOT INCLUDE INDUSTRIAL INSURANCE (WORKERS COMPENSATION)
Departmental Use Only
Amount: _______________________________
Check No: _______________________________
Date Rec’d: _______________________________
Initials: _______________________________
1. Total Premiums/Consideration
1.
2. Gross Premium Tax (3.5% of Line 1 or 2% for RRG, if qualified
2.
3a.
3a.
Home Office Credit, if qualified (NRS 680B.050) 50% or .5 of Line 2 (Form PT-04 and required documents must be attached)
3b. Amount of Ad Valorem Taxes Paid, if qualified for Home Office Credit (NRS 680B.050.)
3b.
3c. Max Credit Allowed
3c.
3d. Allowable Home Office Credits
3d.
4. Subtotal of Premium Tax Due for Calendar Year 20010 (Line 2 minus Line 3d)
4.
5. Life/Health Guaranty Association Offset (NRS 686C)
5.
6. Property/Casualty Guaranty Association Credit (NRS 687A)
6.
A. Total Overpayments applied from previous years
A
B. Total Overpayments refunded by Nevada in 2010
B
7. Net Premium Tax Due
7.
8. Penalty (See Instructions for rate)
8.
9. Daily Interest. Premium Tax Due (Line 7) multiplied by .00049315068 times the number of days late
9.
10. Total Premium Tax Due (Line 7 plus Lines 8 and 9)
10.
If line 10 results in an overpayment, the overpayment may be applied to next years taxes or the overpayment may 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 or Authorized Agent
Date
Telephone
IPT-A
Revised 1-3-11
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