Installment Tax Report - Department Of Insurance - Arizona
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Department of Insurance
State of Arizona
INSTALLMENT TAX REPORT
Financial Affairs Division – Tax unit
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269
YEAR: ______
Telephone: (602) 364-3246
Facsimile: (602) 364-3989
INSTALLMENT TAX REPORTS AND PAYMENTS
You must pay SIX Installment Tax payments if your net annual tax liability was $2,000 or more. Your
net annual tax liability is identified on your annual tax report by the phrase “Installment Tax Base”.
Each Installment Tax payment must equal 15% of the Installment Tax Base amount.
ELECTRONIC PAYMENT OPTION
You can no longer pay taxes and fees by ACH credit. You can electronically pay Installment Taxes
using the NAIC OPTins system.
TO DETERMINE IF YOU MUST PAY INSTALLMENT TAX:
Enter the amount from your annual tax report that appears above
1.
the phrase “Installment Tax Base”
$
IF LINE 1 above is $2,000 OR MORE:
0.00
2.
Enter the result of 15% (0.15) times Line 1
$
DO NOT file reports or pay Installment Tax if Line 1 above is less than $2,000.
TO PAY BY CHECK
You must file this form with each payment made by check payable to Arizona Department of Insurance.
Enter the amount from Line 2 above in the Installment line below for each payment that you are making
with one report. You may file:
• one report for multiple payments, or
• one report for each Installment Tax payment
PENALTY AND INTEREST FOR LATE TAX PAYMENT
Penalty is 5% of the tax paid late, but not less than $25. Interest is 1% of the tax paid late per month.
Complete Company Name
PRINT/TYPE Preparer’s Name and Title
NAIC #
State of Incorporation
Phone
Fax
E-Mail Address
Enter only the amounts you are paying NOW with this report. DO NOT enter amounts for
payments that you previously made or for any future payments.
Installment 1
19
Due MARCH 15
$
20
Installment 2
Due APRIL 15
$
21
Installment 3
Due MAY 15
$
22
Installment 4
Due JUNE 15
$
23
Installment 5
Due JULY 15
$
24
Installment 6
Due AUGUST 15
$
TOTAL PENALTY AND INTEREST INCLUDED FOR THIS REPORT
$
26
0.00
TOTAL
$
This Form is not required if you pay Installment Tax via the NAIC OPTins system
E-INSTALLMENT TAX (R
. 12/08)
P
1
1
EV
AGE
OF
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