Foreign Title Insurer Retaliatory Report - Department Of Insurance - Arizona Page 2
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1
2COMPANY NAME
NAIC NUMBER
TITLE INSURER RETALIATORY TAXES AND FEES COMPUTATION
(A)
(B)
(C)
In the State of Incorporation Column, enter the amounts that an Arizona Title insurer was
ARIZONA
STATE OF
required to pay to your state of incorporation, using your Arizona business as the base amount
INCORPORATION
for fees, assessments and taxes imposed. In the Arizona column, enter only amounts actually
paid in the Calendar Year of this report
.
ATTACH SUPPORTING DOCUMENTATION FOR ALL DEDUCTION AMOUNTS REPORTED
Part 1: TAXES PAYABLE ON STATE OF INCORPORATION BASIS
1.
Arizona Risk Premiums
$
(TI GROSS/TAX)
xxxxxxxxxxxx
2.
State of Incorporation Premium Tax Rate
________
%
0.00
3.
Premium Tax Amount (Line 1 x Tax Rate)
$
Other Taxes or Obligations paid to State of Incorporation - D
A
ESCRIBE AND
TTACH
4.
D
OCUMENTATION
a)
$
b)
$
0.00
5.
Add lines 3, 4a and 4b
$
Arizona State Income Tax liability for the Calendar Year of this report. A
TTACH A COPY
6.
C
I
T
R
P
P
xxxxxxxxxxxxxxx
$
OF
ORPORATE
NCOME
AX
ETURN AND
ROOF OF
AYMENT
Subtotal #1: Retaliatory Tax Due (line 5, Column B, minus Line 6, Column C) NOT
0.00
7.
LESS THAN ZERO
$
xxxxxxxxxxxxxxx
Part 2: FEES & ASSESSMENTS
/
ATTACH COPIES OF PAYMENTS AND
OR SUPPORTING SCHEDULES FOR EACH ITEM
REPORTED
8.
Certificate of Authority renewal fee paid
$
$
135.00
9.
Annual Statement filing fee paid
$
$
300.00
10.
Publication fees paid
[ A
]
$
xxxxxxxxxxxxxxx
TTACH INVOICE
11.
Policies, rates and forms filing fees
$
xxxxxxxxxxxxxxx
12.
Registration Fees or Maintenance Fees
$
xxxxxxxxxxxxxxx
Agent fees, IF APPLICABLE. Attach Form E-AZ AGENTS and enter TOTALS from
13.
Part III, Line J.
$
$
14.
Other fees (filing articles, bylaws, amendments)
$
$
15.
Fraud Fund Assessments
[ A
D
]
$
$
TTACH
OCUMENTATION
16.
Other State of Incorporation Assessments
[ A
D
]
$
xxxxxxxxxxxxxxx
TTACH
OCUMENTATION
435.00
0.00
Subtotal #2 Fees & Assessments (Add lines 8 through 16)
17.
$
$
Subtotal #3 Retaliatory Fees Due (line 17, Column B minus line 17, Column C) NOT
0.00
18.
$
LESS THAN ZERO
0.00
(DOM)
19.
Add lines 5 and 17, Column B
$
Total Retaliatory Amount Due (line 7, Column B plus line 18, Column B).
0.00
(RT)
20.
Carry this amount to Page 1, line 1.
$
E-TITLE.R
(R
. 12/07)
ARIZONA DEPARTMENT OF INSURANCE
P
2
2
ETALIATORY
EV
AGE
OF
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