Form In-1264 - Employer'S Return Of Maine Income Tax Withheld

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STATE OF TENNESSEE
_DEPARTMENT OF COMMERCE AND INSURANCE
Surplus Lines Division
500 James Robertson Parkway, 4th Floor
Nashville, TN 37243-1132
(615) 741-1670
PURCHASING GROUP
PREMIUM TAX REPORT
Total amount of gross taxable premiums including all membership fees, assessments, dues, or any other
consideration for insurance, as provided in the policy or contracts received by ____________________________
agent/representative of the ____________________________________________________________________
Purchasing Group, paid by or for policyholders residing in the State, or on property or risks located in this State, for the tax
period of,
From the ______ day of __________________, 20____
THRU
the ______ day of ____________________, 20____
PREMIUMS
TAX
2 1/2%
State Tax on liability premiums
$ ____________________________
$ ___________________________
TOTAL PREMIUM TAX DUE FOR WHICH CHECK IS ENCLOSED
$___________________________
STATE OF
_____________________________
COUNTY OF
_____________________________
I, ________________________________________, do hereby make oath that the foregoing Statement of
Premiums for Taxation is in accordance with Section 56-14-113, Tennessee Code Annotated, and is true to the
best of my knowledge, information, and belief.
__________________________________________________
Signature of Agent/ Representative
SUBSCRIBED AND SWORN TO BEFORE ME, THIS ________ day of
_________________________, 20____
__________________________________________________
NOTARY PUBLIC
My commission expires on the
__________ day of ________________________________________________
Month
Year
NOTE:
TAXES ARE DUE MARCH 1
for premiums written July 1 through December 31
TAXES ARE DUE SEPTEMBER 1 for premiums written January 1 through June 30
MUST BE FILED IN DUPLICATE
Form IN-1264 (Revised 2-09)

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