Annual Foreignand Domestic Insurance Entities Franchise Tax Report Form

Annual Foreignand Domestic Insurance Entities Franchise Tax Report Form - 2008

Charlie Daniels, Arkansas Secretary of State

ANNUAL FOREIGN AND DOMESTIC INSURANCE ENTITIES

FRANCHISE TAX REPORT 2008

(Authorized Capital Stock)

2007 Tax Year

Reports and Taxes due on or before May 1, 2008. Penalty and Interest will be due for reports if United States Postal Service’s

postmark is after the deadline. Complete report and sign in ink or file over the internet at

Online Filing Available

Correct any information, if needed, in space provided

Tax contact name: ____________________________________

Address: ___________________________________________

Address Line 2: ______________________________________

City, State zip: _______________________________________

Phone #: ___________________________________________

E-mail Address: ______________________________________

Federal Tax ID#

Date of Arkansas Affiliation:

PRINCIPAL ARKANSAS OFFICE ADDRESS:

(Street Address, City, State, Zip)

CAPITAL STOCK:

AUTHORIZED

ISSUED AND OUTSTANDING

Number of Shares

Par Value

Number of Shares

X Par Value =

Extended Par

Value

Common Shares

Preferred Shares

No Par Shares

(NPV) $25.

TOTAL VALUE OF ISSUED AND OUTSTANDING CAPITAL STOCK

NOTE: If the total Issued and Outstanding Capital Stock is less than $500,000 the tax is $300. If the total is $500,000

or more the tax is $400.

TOTAL DUE

State of ________________________ County of ___________________________________________________

I declare, under penalties of perjury, that the above is true and correct, as reflected in the books of the above named

entity as of December 31, 2007.

Executed this ____ day of _____________ , ______ . Signature _______________________________________

(Day)

(Month)

(Year)

Must be signed in ink by: Pres., Vice-Pres., Sec., Treasurer, Controller or Tax Preparer

Due on or before May 1, 2008 – Penalty and Interest due after May 1, 2008

Remittance must accompany this report • Make Checks Payable to Arkansas Secretary of State

Phone 501-682-3409 or 1-888-233-0325

Mail to: Business and Commercial Services Division • P.O. Box 8014 • Little Rock, Arkansas 72203-8014

You may file this electronically over the Internet @

Annual Foreignand Domestic Insurance Entities Franchise Tax Report Form - 2008

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