Installment Tax Report - Department Of Insurance - Arizona

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Department of Insurance
State of Arizona
Financial Affairs Division – Tax unit
INSTALLMENT TAX REPORT
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269
Telephone: (602) 364-3998
Reset
Facsimile: (602) 364-3989
INSTALLMENT TAX REPORTS AND PAYMENTS
th
SIX Installment Tax payments must be paid on or before the 15
day of March, April, May, June, July and
August if your net annual tax liability was $2,000 or more. Find your net annual tax liability on Page 2, Line 14
of Form E-ANNUALTAX or Page 3, Line 3 of Form E-HEALTHORG with the phrase “Installment Tax Base”.
Your required Installment Tax payments are 15% of the Installment Tax Base amount.
STEP 1 - DETERMINE IF YOU MUST PAY INSTALLMENT TAX
Enter the amount reported on Line 14 of Form E-ANNUALTAX or Line 3 (Page 3) of
1.
Form E-HEALTHORG. This is your Installment Tax Base* amount.
$
0.00
2.
IF LINE 1 above is $2,000 OR MORE: 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.
*THE DEPARTMENT WILL NOTIFY YOU IF THERE IS A DISCREPANCY IN THE INSTALLMENT TAX BASE AMOUNT OR IF AN AUDIT
RESULTS IN A CHANGE TO THE INSTALLMENT TAX BASE AMOUNT.
STEP 2 – FILE INSTALLMENT TAX REPORTS
Detach the form below to make SIX copies for your Installment Tax payments. Enter the Line 2 amount
above on the line(s) in the form for the payment(s) you are making. You may file one report for multiple
payments or one report for each Installment Tax payment. You must file reports even if you pay by ACH credit.
STEP 3 – PAY BY CHECK OR ACH CREDIT
To pay by check, mail the Form below with your check payable to the Arizona Department of Insurance. For
ACH credit payment, mark the box and see Form E-ACH.INSTRUCTION.
LATE PAYMENTS – PENALTY AND INTEREST
If your payment is late, penalty and interest will apply. Penalty is 5% of the tax paid late, but not less than $25.
Interest is 1% of the tax paid late per month.
-----------------------------------------------------------------------------------------CUT OR TEAR HERE---------------------------------------------------------------------
ARIZONA DEPARTMENT OF INSURANCE
INSTALLMENT TAX REPORT
2007
Fold so that address appears in window and mail to:
Enter Year:
Arizona Department of Insurance
Financial Affairs Division – Tax Unit
th
2910 North 44
Street Suite 210
Phoenix, Arizona 85018-7269
Complete Company Name
PRINT/TYPE Preparer’s Name and Title
NAIC #
State of Incorporation
Phone
Fax
E-Mail Address
DUE DATE
PAYMENT AMOUNT
PAY CODE
19
MARCH 15
$
20
Enter amounts paid by
APRIL 15
$
check or ACH credit for
21
MAY 15
$
this Report only
22
JUNE 15
$
JULY 15
$
23
24
AUGUST 15
$
0.00
TOTAL OF INSTALLMENT TAX PAYMENTS FOR THIS REPORT
$
TOTAL PENALTY AND INTEREST INCLUDED
$
26
MARK ONE BOX:
Check payable to the Arizona Department of Insurance is enclosed.
ACH credit delivery will be sent (see Form E-ACH.INSTRUCTION).
E-INSTALLMENT TAX (R
. 02/08)
P
1
1
EV
AGE
OF

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