2004 Annual Tax And Fees Report - Arizona Department Of Insurance Page 3

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COMPANY NAME _____________________________________________________________ NAIC NO. ____________

PART B - ARIZONA TAXES DUE FOR CALENDAR YEAR 2004

Gross Tax Amount from Part A, Page 2, line 5

(GT)

Less Allowable Credits

Enterprise Zone Credit from Form E-ZONE

(EZC)

Military Reuse Zone Credit from Form M-ZONE

(MZC)

0.00

c) Total (line 1a plus line 1b)

(TAO)

d) Enter the LESSER amount of line 1 or 1c

(TC)

Net Tax Amount (line 1 minus line 1d)

(2005 Installment Tax Base)

(IB)

Less: 2004 Installment Taxes Paid (excluding penalty or interest)

a) March 15, 2004

b) April 15, 2004

c) May 15, 2004

d) June 15, 2004

e) July 15, 2004

f) August 15, 2004

g) Total of lines 3a through 3f

0.00

(-)$

(TIP)

Enter the result of line 2 minus line 3g on line 4a if positive, or on 4b if negative.

a) Tax due with this report – carry to Part C, Page 1, line 1

(NT)

b) Overpayment of tax – to be refunded pursuant to A.R.S. § 20-224.02

(SR)

* WARNING!

DO NOT ATTEMPT TO APPLY A TAX OVERPAYMENT TO ANNUAL FEES DUE WITH THIS REPORT. YOUR OVERPAYMENT

WILL BE REFUNDED WITHIN 90 DAYS OF THE DUE DATE OF THIS REPORT. ANNUAL FEES MUST BE PAID WITH THIS RETURN.

CONTINUE TO PART C ON PAGE 1 FOR SUMMARY AND SIGNATURES

PENALTY FOR LATE PAYMENT OF TAX:

Late payment of tax is subject to a civil penalty equal to the greater of $25 or 5% of the tax paid late, plus interest at the rate of 1% of the tax paid late

per month from the date the tax was due.

E-HEALTHORG (R

. 12/04)

STATE OF ARIZONA

AGE