Form Pti-01(A) - Annual Industrial Insurance (Workers Compensation) Premium Tax Return - 2003
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1
2Nevada Department of Taxation
Company ID:New:_______Old:_____
DUE DATE MARCH 15, 2004
1550 E. College Parkway Rm. 115
Carson City NV 89706
Federal ID:__________________
Phone: (775) 684-2000
Fax: (775) 684-2020
Premium Tax:__________________
ANNUAL INDUSTRIAL INSURANCE (WORKERS COMPENSATION)
Retaliatory Tax:__________________
PREMIUM TAX RETURN 2003
Total Remittance:__________________
DEPARTMENT USE ONLY
Amount ____________________________
Check No. __________________________
Date Rec'd __________________________
Initials ______________________________
(A)
(B)
Net Quarterly Taxable Premiums/Considerations
REPORTED
ACTUAL
1
1. March 31, 2003
2. June 30, 2003
2
3. September 30, 2003
3
4. December 31, 2003
4
5. Total Premiums/Considerations (Add Lines 1 through 4)
5
6. Total Premiums/Considerations (Line 5, Column B - Must agree with Schedule 1, Line 3A)
6
7. Gross Premium Tax (3.5% of Line 6 - Must agree with Schedule 1, Line 4A)
7
(
)
8. Industrial Insurance Credit (Workers Compensation) (NRS 680B.036)
8
9. Net Premium Tax Due for Calendar Year 2003 (Line 7 less Line 8)
9
10. Home Office Credit, if qualified (NRS 680B.050) (50% or.5 of Line 9) (Attach Form PT-04 and req. documents)
10
(
)
11. Total Cash Payments made with Quarterly Returns
11
(
)
12. Total Overpayment carried forward from 2002
12
13. Total Overpayment refunded by Nevada in 2003
13
14. Overpayment Remaining (Line 12 minus Line 13)
14
(
)
15. Net Premium Tax Due
15
16. Penalty 10% or .10 of line 15 (if postmarked after due date)
16
17. Interest 1.5% or .015 of Line 15 (If postmarked after due date, for each month or fraction of a month past due)
17
18. Total Premium Tax Due (Line 15 plus Lines 16 and 17)
18
A COPY OF THE NEVADA PAGE FROM ANNUAL STATEMENT MUST BE ATTACHED.
NRS REQUIRES THIS RETURN MUST BE SIGNED
I hereby declare under penalty of perjury that this premium tax report (including any accompanying schedules and statements) has been examined by me and
is a true, correct and complete report.
SIGNATURE OF TAXPAYER OR AUTHORIZED AGENT
PRINTED NAME OF TAXPAYER OR AUTHORIZED AGENT
DATE
TELEPHONE #
DEPARTMENT USE ONLY
PTI-01(A)
Revised 12/31/03
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