Form 74a101 - Insurance Premiums Tax Return Form printable pdf download

Form 74a101 - Insurance Premiums Tax Return Form

74A101 (12-03)

Commonwealth of Kentucky

Domestic Mutual, Domestic Mutual Fire

FOR OFFICIAL USE ONLY

REVENUE CABINET

or Cooperative and Assessment

2 0

0 0 1

___ ___ / ___ ___ ___ ___ / ___ ___ ___ / ___

Fire Insurance Companies

Tax

Year

Pmt. Code

Tr.

Account Number ___ ___ ___ ___ ___

FOR CALENDAR YEAR 20___

INSURANCE PREMIUMS TAX RETURN

NAIC/

FEIN __ __ – __ __ __ __ __ __ __

TAX ID

Company Name

Home Office Address (Number and Street)

Mailing Address (Post Office Box)

Telephone Number

City

State

ZIP Code

SECTION I—REPORT OF PREMIUMS PAID TO UNAUTHORIZED REINSURANCE COMPANIES

Name of Unauthorized

Amounts of

Address

Reinsurance Company

Premiums Paid

Total Premiums Paid to Unauthorized Reinsurance Companies ......................................................

Tax Liability—2% of Total Unauthorized Premiums .......................................................................

Make check payable to Kentucky State Treasurer and mail return with payment to:

KENTUCKY REVENUE CABINET

Mailing Address:

P.O. Box 1303, Frankfort, KY 40602-1303

Overnight Address:

1266 Louisville Road, Frankfort, KY 40601

I, the undersigned, declare under the penalties of perjury, that I have examined these returns, including all accompanying schedules and statements, and

to the best of my knowledge and belief, they are true, correct and complete.

_______________________________________

________________________________

_________

Signature of President or Chief Accounting Officer

Print Name

Date

REPORT PREPARER’S INFORMATION

_______________________________________

________________________________

_________

Title

Date

Signature

_______________________________________

________________________________

(

)

Print Name

Telephone Number

Form 74a101 - Insurance Premiums Tax Return Form

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