Form Dr-907 - Florida Insurance Premium Installment Payment - 2004

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DR-907
Florida Insurance Premium Installment Payment
R. 01/04
US Dollars
Cents
FEIN
Florida Code
1. Premium tax payable
,
,
2. Surcharge
,
Handwritten Example
Typed Example
a. commercial policies
0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 6 6 6 6 6 7 7 7 7 7 8 8 8 8 8 9 9 9 9 9
0123456789
# _________________ x $4
DR-907
Use black ink.
,
b. residential policies
Payment Number 1 Tax Year
# _________________ x $2
Due April 15
3. Interest
,
4. Penalty
,
Name
Address
City/St/ZIP
5. Quarterly statement filing fee
,
• Does not apply to surplus lines agents
or surplus lines companies.
,
,
6. Amount due
Check here if you transferred payment electronically.
Be sure to sign and date reverse side.
Mail form and remittance to:
9999090999999990001604503301039999999990000002
FLORIDA DEPARTMENT OF REVENUE
5050 W TENNESSEE STREET
TALLAHASSEE FL 32399-0150
DR-907
Florida Insurance Premium Installment Payment
R. 01/04
US Dollars
Cents
FEIN
Florida Code
1. Premium tax payable
,
,
2. Surcharge
,
Handwritten Example
Typed Example
a. commercial policies
0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 6 6 6 6 6 7 7 7 7 7 8 8 8 8 8 9 9 9 9 9
0123456789
# _________________ x $4
DR-907
Use black ink.
,
b. residential policies
Payment Number 2 Tax Year
# _________________ x $2
Due June 15 (Estimate premiums through June 30)
3. Interest
,
4. Penalty
,
Name
Address
City/St/ZIP
5. Quarterly statement filing fee
,
• Does not apply to surplus lines agents
or surplus lines companies.
6. Amount due
,
,
Check here if you transferred payment electronically.
Be sure to sign and date reverse side.
Mail form and remittance to:
9999090999999990001604503301039999999990000002
FLORIDA DEPARTMENT OF REVENUE
5050 W TENNESSEE STREET
TALLAHASSEE FL 32399-0150
DR-907
Florida Insurance Premium Installment Payment
R. 01/04
US Dollars
Cents
FEIN
Florida Code
1. Premium tax payable
,
,
2. Surcharge
,
Handwritten Example
Typed Example
a. commercial policies
0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 6 6 6 6 6 7 7 7 7 7 8 8 8 8 8 9 9 9 9 9
0123456789
# _________________ x $4
DR-907
Use black ink.
,
b. residential policies
Payment Number 3 Tax Year
# _________________ x $2
Due October 15
3. Interest
,
4. Penalty
,
Name
Address
City/St/ZIP
5. Quarterly statement filing fee
,
• Does not apply to surplus lines agents
or surplus lines companies.
6. Amount due
,
,
Check here if you transferred payment electronically.
Be sure to sign and date reverse side.
Mail form and remittance to:
9999090999999990001604503301039999999990000002
FLORIDA DEPARTMENT OF REVENUE
5050 W TENNESSEE STREET
TALLAHASSEE FL 32399-0150

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