Form 6136 - Insurance Tax Return Life And Accident And Health Companies 2011 Page 4
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5Indiana Department of Insurance
Premium Tax Filings – Credit Worksheet for Guaranty Fund Assessments
NAIC Number:
__________________
State of Domicile: __________________
Company Name:
___________________________________________________________________________________
The “Membership Assessment History Report” (Report), previously produced by the Indiana Guaranty Fund Office may be used
as proof of payment for credit taken on the Indiana Premium Tax Return if available. The Guaranty Fund office no longer
produces this report but past reports will suffice until the credits are utilized in full. For 2005 and subsequent guaranty fund
assessments the company must provide the Tax Offset Statement, Assessment/Refund Statement and cancelled check (front and
back) for each credit being reported. The proof is required to be submitted each and every year a credit is reported. The
Guaranty Fund office may be contacted at 317-636-8204.
To receive credit however, the following must be provided:
1.
Create a separate worksheet for each type of credit taken.
2.
Denote (X) appropriate box for type of credit listed.
3.
Calculate all assessments paid, less refunds and enter the total using the date received/refund given from the “Report”
or the date posted from the canceled check.
4.
List assessments and/or refunds newest (top) to oldest (bottom). The cumulative total for the year in which the
assessments or refunds were paid/refunded should be entered in the Amount column with the year paid in the date
posted column.
5.
Enter twenty percent of the total in the appropriate box according to which year the credit is currently representing.
6.
A negative credit is to be included as income and calculated in the sum of total tax due.
NOTE: Proof of payment (canceled check) and Assessment Statement required with worksheet for assessment credit taken.
( ) Worksheet for Indiana Life and Health Guaranty Fund Assessment (20%) *
( ) Worksheet for Indiana Guaranty Fund Assessments (20%) *
* Percent of the assessments paid in the prior calendar year
Date
Check#
Amount
Year #1
Year #2
Year #3
Year #4
Year #5
Total
Posted
$
$
$
$
$
Carry Forward Credit
(Unused credit
from prior year)
$
Total Credit Eligible
$
Credit Used -
Report amount on Schedule 1
(Amount may not exceed tax liability
$
Credit to carry forward for next year:
$
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