Form Ip-1 - Insurance Premium Tax Return - 2004
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1
2Form IP-1
2004 VERMONT INSURANCE PREMIUM TAX RETURN
MAIL REPORT WITH TAX PAYMENTS TO:
VERMONT DEPARTMENT OF TAXES
TAXPAYER SERVICES DIVISION
109 STATE STREET
MONTPELIER, VT 05609-1401
Return Due Date: February 28, 2005
Print or type complete name and address below:
Date Organized:
Under the laws of the State of:
Fed. ID #
Date first licensed to do business in VT:
Computation of Insurance Premium Tax on all business Property and Casualty Companies
State of Incorporation
State of Vermont
reported in SCH.T - excluding A & H (must report A & H on reverse).
Basis
Basis
1. Gross direct premiums written on businesses in Vermont during the year.
1.
$
$
2. If a Vermont company, indicate gross direct premiums
in other states and not taxed by other states.
2.
3. TOTAL PREMIUMS (Add Lines 1 & 2)
3.
4. Dividends paid or credited to policyholders
4.
5. Return premiums
5.
6. Other deductions (please specify)
6.
7. TOTAL DEDUCTIONS (Add Lines 4 - 6)
7.
8. TAXABLE PREMIUMS (Subtract Line 7 from Line 3)
8.
9. Tax at rate of _______________ % (2% for Vermont)
9.
10. Life, Accident and Health and Annuity Tax from Line 35
10.
11. TOTAL INSURANCE PREMIUM TAX (Add Lines 9 & 10)
11.
12. LESS: Tax paid on estimated returns
12.
13. OVERPAYMENT: If Line 12 is larger than Line 11 enter overpayment
13.
14. Amount of overpayment to be credited to 2005 estimated tax: 14.
15. REFUND DUE:
15.
16. BALANCE DUE: If Line 11 is larger than Line 12 enter amount due
Make your check payable to VERMONT DEPARTMENT OF TAXES
16.
I hereby certify this return is true, correct and complete to the best of my knowledge.
Signature of Responsible Officer
Title
Date
Signature of Preparer Other Than Officer
Title/Firm Name
Date
Form IP-1
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