Form Ins-4 - Insurance Premiums Tax Return

Form Ins-4 - Insurance Premiums Tax Return - 2005 Page 4

FORM INS-4

SCHEDULE 3

CAPTIVE INSURANCE COMPANIES

PREMIUMS TAX

For Form INS-4, Part C, line 17

MRS Insurance

2005

Taxpayer Name ____________________________ Account Number _________________________ Tax Year ______________

This schedule is used to calculate the amount of all Captive Insurance Companies premiums on insurance

written on risks located in, or received from risk members of, the State of Maine during the above period.

Type of Insurance authorized to write: _____________________________________________________

Name of Parent Company _________________________________________________

Federal EIN ____________________

Parent Company Corporate Domicile ________________________________________

______________________________

City

State

Insurance Premiums

1. Direct premiums and all related fees and charges ........................................ 1. ____________________

2. Return premiums .......................................................................................... 2. ____________________

3. Dividends paid, credited, or allowed on premiums ........................................ 3. ____________________

4. Net direct premiums (line 1 minus lines 2 and 3) .......................................... 4. ____________________

5. Tax on insurance premiums (see instructions) .......................................... 5. ____________________

Assumed Reinsurance Premiums

6. Assumed reinsurance premiums .................................................................. 6. ____________________

7. Tax on assumed reinsurance premiums (see instructions) ...................... 7. ____________________

8. Total tax (line 5 plus line 7) ........................................................................... 8. ____________________

$4,000.00

9. Alternative minimum tax ............................................................................... 9. ____________________

10.Total tax - Enter the greater of line 8 or line 9 here

and on F

INS-4, line 17 ......................................................................... 10. ____________________

ORM

Form Ins-4 - Insurance Premiums Tax Return - 2005 Page 4