Form A - Premium Tax Return Life Companies - 2014 printable pdf download

Form A - Premium Tax Return Life Companies - 2014

IOWA DEPARTMENT OF COMMERCE

INSURANCE DIVISION

PREMIUM TAX RETURN LIFE COMPANIES

CALENDAR YEAR ENDED DECEMBER 31, 2014

Taxes must be received on or before March 1. Separate filings and checks are required for each company. The payments received are subject

to audit and subsequent adjustments, if any.

NAIC Co. No.

State Of Domicile

Iowa Co. No.

Company name:

Address:

Make the company check payable to:

TREASURER, STATE OF IOWA

• The amount of the check is the total on line 45

When you pay by check, you authorize the State of Iowa to convert your check to a

•

one-time electronic banking transaction.

Department of Revenue

• Submit the PREMIUM TAX RETURN and check to:

Hoover Building, 3rd Floor, P.O. Box 10455

1305 E. Walnut

Des Moines, Iowa 50319

Col. 1

Col. 2

H Premiums

State of

State of Iowa

Incorporation Basis

Basis

1. Premiums per "Direct Writings" Schedule T of the Annual Statement

DEDUCTIONS

2. Dividends paid in cash or credited to insureds

4. Other (specify)

Total deductions

6. Net taxable premiums (Item 1 less 5)

7. Tax at rate of ______% (1% for Iowa)

XXXX

8. Other (specify)*

Totals ( Item 7 and 8)

*Attach an exhibit showing the statutory reference(s) and the details of your computations of state income tax and any other special taxes. Special taxes

include, but are not limited to those levied for maintenance of boards, bureaus, departments, etc., under statutory provisions of your state, which an

Iowa company, licensed in your state, would be required to pay. The total of such taxes or assessments is to be entered on line 8 above.

*1410002010001*