2000 Annual Fees Report - Arizona Department Of Insurance
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1ARIZONA DEPARTMENT OF INSURANCE
DUE DATE: FEBRUARY 28, 2002
2000 ANNUAL FEES REPORT
FOREIGN AND ALIEN QUALIFIED REINSURER TRUST PURSUANT TO A.R.S. § 20-261.01(A)(4)
PREMIUM TAX UNIT
(602) 912-8429
FAX (602) 912-8421
For Office Use Only
For Audit Use Only
ORIGINAL REPORT
AMENDED REPORT / REASON _______________________________________________________________________________
Complete Company Name and Home Office Address
State or Country of Domicile
x
x
Arizona I. D. Number
x
Federal I. D. Number
x
x
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
1)
Annual Statement Filing Fee
$
300.00
(Pay Code 28)
2)
TOTAL DUE FEBRUARY 28, 2002
$
300.00
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AKE CHECK PAYABLE TO AND
Attention: TAX UNIT
M
:
2910 North 44
Street, Second Floor
AIL CHECK WITH REPORT TO
th
Phoenix, Arizona 85018-7256
PREPARER CERTIFICATION
COMPANY OFFICER CERTIFICATION
I certify that I have prepared this report. It is true, complete and correct to the
I certify that I have examined this report. It is true, complete and correct to the best
best of my knowledge.
of my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-QRT (R
. 12/01)
P
1
1
EV
AGE
OF
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