Form Ib-64 - Health Maintenance Organization
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1Installment Payment - April 16, 2007
IB-64
I-B
Health Maintenance Organization
Web
Insurance
5-07
North Carolina Department of Revenue
Legal Name (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Fill in circle if applicable:
Payment has been made through
Mailing Address
electronic funds transfer (EFT)
HMO
City
State
Zip Code
Federal Employer ID Number
Name and title of person responsible for the computation and filing of this return
Phone Number (Include area code)
(
)
Part 1. Computation of Gross Premium Tax Installment
.
,
,
00
1.
Estimated taxable gross premiums to be written in N.C. in calendar 2007
1.
.
,
,
2.
Estimated gross premium tax due for calendar 2007
00
2.
Multiply Line 1 by 1.9% (.019)
.
,
,
3.
Gross premium tax installment due
00
3.
Multiply Line 2 by 50% (.50)
.
,
,
4.
Portion of 2006 overpayment of gross premium tax applied as credit
00
4.
(From Form IB-63, Part 1, Line 8)
.
,
,
5.
Net gross premium tax installment due
00
5.
Line 3 minus Line 4
Part 2. Computation of Insurance Regulatory Charge Installment
.
,
,
6.
Estimated insurance regulatory charge liability
00
6.
Multiply Line 2 by 5.5% (.055)
.
,
,
7.
Insurance regulatory charge installment due
00
7.
Multiply Line 6 by 50% (.50)
.
,
,
8.
Portion of 2006 overpayment of insurance regulatory applied as credit
00
8.
(From Form IB-63, Part 2, Line 15)
.
,
,
9.
Net insurance regulatory charge installment due
00
9.
8.
Line 7 minus Line 8
Part 3. Amount of Installment Due
,
,
.
$
10.
Total April 16, 2007 installment due
00
10.
9.
Line 5 plus Line 9
Signature:
Title:
Date:
I certify that, to the best of my knowledge, this return is accurate and complete.
Make check or money order in U.S. currency payable to North Carolina Department of Revenue.
MAIL TO: North Carolina Department of Revenue, Insurance Premium Tax Unit, P.O. Box 25000, Raleigh, NC 27640-0300
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