Form Ins-4 - Insurance Premiums Tax Return

MAINE REVENUE SERVICES

FORM INS-4, Page 2

2005

INSURANCE PREMIUMS TAX RETURN

*0530001*

MRS Insurance Account Number

Part B – Retaliatory Computation

Enter the United States Postal Service two letter state abbreviation for your state of incorporation:

.00

12. Gross Premiums (Schedule 2, line 1, Column H) ........................................................................................ 12.

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13. Allowable Deductions (Schedule 2, line 2, Column H) ................................................................................. 13.

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14. Net Taxable Premiums (Schedule 2, line 3, Column H) ............................................................................... 14.

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15. Premium Tax on basis of state of incorporation (Schedule 2, line 5, Column H) .......................................... 15.

Part C – Tax Due

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16. Enter the greater of Part A, line 11 or Part B, line 15 .................................................................................... 16.

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17. Tax on net premiums on captive insurance companies from Schedule 3, line 10 ........................................ 17.

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18. Less: Prior Payments .................................................................................................................................. 18.

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19. Tax Credits (Attach schedule – cannot exceed the total of lines 16 and 17) ................................................. 19.

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20. Balance Due (If the sum of lines 16 and 17 is greater than the sum of lines 18 and19, enter amount) ........ 20.

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21. Overpayment (If the sum of lines 18 and19 is greater than the sum of lines 16 and 17, enter amount) ....... 21.

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22a. Portion of overpayment to be APPLIED to next year’s ESTIMATED tax .................................................. 22a.

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22b. Portion of overpayment to be REFUNDED .............................................................................................. 22b.

2006 Quarterly Estimated Tax Election

An authorized company official must elect an annual method of reporting quarterly estimated premiums taxes for 2006. These 2006 payments may be on an

estimated basis, as long as the May 1 and June 26 installments each equal at least 35% of the total tax paid for 2005 or 35% of the total tax due for 2006,

whichever is elected. The October 31 installment must equal 15% of the total tax paid for 2005 or 15% of the total tax due for 2006. The elected method cannot

be changed during the calendar year (36 M.R.S.A . § 2521-A). Do not complete this election if this is an amended return.

2006 Estimated tax due will be based on total tax paid for 2005 ....................................................................

2006 Estimated tax due will be based on the estimated tax liability for 2006. ...............................................

Affidavit and Signature

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and

belief, they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Date _________________________ Signature ____________________________________________ Title _______________________________

Must be signed by the President, Treasurer, Secretary, Chief Accounting Officer, or Attorney-in-fact of a Reciprocal Insurer.

Contact Person ______________________________________________________________________ Phone # ____________________________

Preparer’s

Date _________________________ Signature ____________________________________________ ID Number __________________________

Important Note:

Your return must include required attachments. See page 3 of the instructions for more information.

Make check payable to:

Treasurer, State of Maine

Office

Send check and return to:

Maine Revenue Services, P.O.Box 9120, Augusta, ME 04332-9120