Looking for a Nevada Department Of Taxation Forms And Templates? Download it for free!

Form Pti-01(A) - Annual Industrial Insurance (Workers Compensation) Premium Tax Return - 2003 Page 2

Nevada Department of Taxation

SCHEDULE 1

INDUSTRIAL INSURANCE PREMIUM TAX AND FEES ON RETALIATORY BASIS

(WORKERS COMPENSATION) For Year Ending December 31, 2003

(A)

(B)

NEVADA BASIS

STATE OF INC

1. Gross Annual Premiums (Industrial Insurance Only)

2. Dividends Paid or Credited to Policy Holders

3. Gross Premiums written minus Dividends paid or Credited to Policy Holders

4. Taxes Payable (according to applicable rate) (Tax Rate for Nevada is 3.5%)

Must agree with Line 7, PTI-01(A) on annual return

5. Retaliatory Assessment

This return must be filed even if no tax is due. (For companies required to file quarterly, the annual return is

a summary of the calendar year.)

The Nevada premium tax rate is 3.5%. Retaliatory statutes, NRS 680A.330, require you to use the higher tax

rate charged by Nevada or your domiciliary state.

INSTRUCTIONS

SCHEDULE 1

Line 1 Gross Annual Premiums for Industrial Insurance Only (Workers Compensation). Premiums include

policy, membership, and other fees and assessments.

Line 2 Amount of dividends paid or credited to policy holders.

Line 3 Gross premiums written minus dividends paid or credited to policy holders.

Line 4 Taxes payable. If the state of domicile taxes the premium at a different rate, a separate schedule

calculating the tax in accordance with the domiciliary state method must be attached and the tax amount entered

on Line 5 only, State of Inc.

ANNUAL RETURN

This return is for Industrial Insurance (Workers Compensation)

Lines 1 through 4 If figures for Columns A and B differ, penalty and interest may apply.

Line 18 Total Premium Tax Due. If the calculated amount entered on this line results in a negative figure, this

amount is the premium tax overpayment that will be credited to your account. If you owe premium tax and/or

retaliatory assessment, make the check payable to the Department of Taxation.

PTI-01(B)

Revised 12/31/03

Form Pti-01(A) - Annual Industrial Insurance (Workers Compensation) Premium Tax Return - 2003 Page 2