Form In-1264 - Purchasing Group Statement Of Premiums And Tax Payment

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STATE OF TENNESSEE
DEPARTM ENT OF COM M ERCE AND I NSURANCE
Surplus Lines Division
500 James Robertson Parkway, 7th Floor
Office Use Only
Nashville, TN 37243
Reviewed By (I nitial/Date)
(615) 741-1756
________________________
PURCHASING GROUP STATEMENT OF PREMIUMS AND TAX PAYMENT
Total amount of gross taxable premiums includes all premiums, membership fees, assessments, dues, or any other consideration for
insurance, as provided in the policy or contracts received by _________________________________________________ agent or
representative of the ______________________________________________________________ Purchasing Group (Legal Name)
__________________ (FEIN #) located at _______________________________________________________________ (Address)
__________________________________________(City, State, Zip Code)____________________ (Phone Number), paid by or for
policyholders residing in the State, or on property or risks located in this State.
Office Use Only
Premiums
Tax
2.5% State Tax on Liability Premiums if obtained from an
$
$
CI 759
121/127
authorized insurer
5.0% State Tax on Liability Premiums if obtained from an
$
$
CI 759
121/127
eligible surplus lines insurer
Tax Period:
From (Month/Day/Year)
To (Month/Day/Year)
STATE OF
_____________________________
COUNTY OF _____________________________
I, ________________________________________, do hereby make oath that the foregoing Purchasing Group Statement of Premiums
and Tax Payment is in accordance with Tenn. Code Ann. § 56-45-110, and is true to the best of my knowledge, information, and belief.
____________________________________________________________
Signature of Agent or Representative
SUBSCRIBED AND SWORN TO BEFORE ME, THIS __________ day of ____________________________________________
MONTH
YEAR
____________________________________________________________
NOTARY PUBLIC
My commission expires on the ____________ day of ____________________________________________________________
MONTH
YEAR
NOTE: Taxes are due by MARCH 1 for the tax period of January 1 through December 31 immediately preceding.
Make check payable to:
Tennessee Department of Commerce & Insurance
Mail check to:
State of Tennessee
The Department of Commerce & Insurance
P.O. Box 198983
Nashville, TN 37219-8983
If you have any questions or need assistance in filling out the form, please contact the Surplus Lines Division at (615) 741-1756.
Form IN-1264 (Revised 5-2014)
RDA 745

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