Annual Foreign And Domestic Insurance Entities Franchise Tax Report (Authorized Capital Stock) - Arkansas Secretary Of State - 2010

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Charlie Daniels, Arkansas Secretary of State
ANNUAL FOREIGN AND DOMESTIC INSURANCE ENTITIES
FRANCHISE TAX REPORT 2010
(Authorized Capital Stock)
For the year ending 12/31/2009
Reports and Taxes are due on or before May 1, 2010. Penalty and Interest will be due for reports if the United States Postal Service’s
postmark is after the deadline. Complete this report online at or sign in ink and mail to the address
listed below.
1.
Correct any information, if needed, in space provided below
2.
Tax contact name: ____________________________________
Save time, file online at anytime
Address: ____________________________________________
day or night at
Address Line 2: _______________________________________
.
City, State, Zip: _______________________________________
Phone # of tax contact: _________________________________
E-mail address: _______________________________________
TOTAL AUTHORIZED CAPITAL STOCK:
5.
(See Instruction 13)
Required Information
NUMBER OF SHARES
PAR VALUE EACH
*a
Federal Tax ID# ______________________________________
*b
$
Date of Arkansas Affiliation _____________________________
*c
$
3.
___A
4, 5 & 6
LL OF THE INFORMATION IN SECTION
HAS BEEN
NO PAR VALUE =$25 PER SHARE
VERIFIED AND HAS BEEN FOUND TO BE EXACTLY THE SAME AS
.
LAST YEARS REPORT
6.
ISSUED AND OUTSTANDING CAPITAL STOCK:
(See Instruction 14)
Principal Arkansas Office Address
NUMBER OF
PAR VALUE EACH
$ TOTAL
4.
Street Address _____________________________________
SHARES
*a
X $
= $
Address Line 2_____________________________________
*b
X $
= $
City, State, Zip _____________________________________
*c
= $
X $
No PV=$25 per share
*d
(Add 6a +6b + 6c)
= $
TOTAL:
NOTE: The Franchise Tax is based on the Issued and Outstanding Capital Stock per the TOTAL. If the total is
less than $500,000.00 the tax is $300.00 If the total is $500,000.00 or more the tax is $400.00.
Total Due
$
State of ______________________________________, County of _____________________________________.
I declare, under the penalties of perjury, that the foregoing statements are true to the best of my knowledge and belief.
Signature________________________________________ Executed this _________ day of __________________, ____________
Must be signed in ink by: Pres., Vice-Pres., Sec., Treasurer, Controller or Tax Preparer
(Day)
(Month)
(Year)
Due on or before May 1, 2010 – Penalty and Interest due after May 1, 2010
You may file this electronically over the Internet @
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

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