Form Ins-7 - Surplus Lines Premiums Tax Annual / Reconciliation Return

FORM INS-7

MAINE REVENUE SERVICES

2005

SURPLUS LINES PREMIUMS TAX

*0532000*

ANNUAL / RECONCILIATION RETURN

Period Covered

Producer’s SSN

Due Date

0 1

January 1- December 31, 2005

March 15, 2006

Producer’s Name, Address and Name of Producer’s Company or Employer:

CHECK ALL THAT APPLY:

Initial return

Producer’s Name

Amended return

Street Address and/or Post Office Box

Made estimated payments

during the year

City

State

ZIP Code

Change of name/address

Name of Producer’s Company or Employer

Tax Computation

.00

Gross Direct Surplus Line Premiums ............................................................................ 1.

DEDUCTIONS

.00

2a. Return premiums .......................................................................................................... 2a.

.00

2b. Dividends paid, credited or allowed on direct premiums ............................................ 2b.

.00

Total Deductions (line 2a plus line 2b) ........................................................................... 3.

.00

Amount Taxable (line 1 minus line 3) ............................................................................. 4.

.00

Premiums Tax (line 4 x 0.03) ......................................................................................... 5.

.00

Less: Prior Payments ..................................................................................................... 6.

.00

Balance Due (If line 5 is greater than line 6, line 5 minus line 6) .................................. 7.

.00

Overpayment (If line 6 is greater than line 5, line 6 minus line 5) ................................ 8.

.00

9a. Portion of overpayment to be APPLIED to next year’s ESTIMATED tax .................... 9a.

.00

9b. Portion of overpayment to be REFUNDED (line 8 minus line 9a)... ........................... 9b.

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

This return is made in compliance with the provisions of 36 M.R.S.A. § 2521-A. The amount of all Surplus Lines Premiums on insurance written by this producer on

risks located in, or received from risks resident of, the State of Maine during the above period has been reported. 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 ____________________________________________

Phone # ___________________________

Must be signed by the Producer with Surplus Lines Authority.

Preparer’s

Date _________________________ Signature ____________________________________________ ID Number __________________________

Office

Make check payable to :

Treasurer, State of Maine

use only

Send return with check to:

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