Form Ins-7 - Surplus Lines Premium Tax Annual / Reconciliation Return

FORM INS-7

MAINE REVENUE SERVICES

SURPLUS LINES PREMIUM TAX

*0432000*

ANNUAL / RECONCILIATION RETURN

Period Covered

Producer’s SSN

Due Date

January 1- December 31, 2004

March 15, 2005

0 1

Producer’s Name, Address and Name of Producer’s Company or Employer:

CHECK APPLICABLE SPACES:

Initial return

Producer’s Name

Amended return

Final return

Street Address and/or Post Office Box

Enter closing date: ___ /___ /_____

Made estimated payments

City

State

Zip Code

during the year

Change of name/address

Name of Producer’s Company or Employer

Tax Computation

.00

1. Direct Surplus Line Premiums .................................................................................................................... 1.

2. DEDUCTIONS

.00

a. Return premiums ....................................................................................................................................... 2a.

.00

b. Dividends paid, credited or allowed on direct premiums ........................................................................ 2b.

.00

3. Total Deductions (line 2a plus line 2b) ........................................................................................................ 3.

.00

4. Amount Taxable (line 1 minus line 3) ........................................................................................................... 4.

.00

5. Amount of Premium Tax (line 4 x 0.03) ....................................................................................................... 5.

.00

6. Less:Prior Payments ................................................................................................................................... 6.

.00

7. Balance Due (line 5 minus line 6) ................................................................................................................ 7.

.00

8. Overpayment (line 6 minus line 5) ............................................................................................................. 8.

.00

9. Amount credited to next year’s liability .... 9a.

9b. Refunded...9b.

This return is made in compliance with the provisions of 36 M.R.S.A. § 2521-A. The amount of all Surplus Lines Premiums on insurance written by

this producer on risks located in, or received from risks resident of, the State of Maine during the above period has been reported. Under penalties of

perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,

correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Phone # ___________________________

Date __________________________ Signature ____________________________________________

Must be signed by the Producer with Surplus Lines Authority.

Preparer’s

Date __________________________ Signature ____________________________________________ ID Number __________________________

Make check payable to :

Treasurer, State of Maine

Send return with check to:

Maine Revenue Services, P.O.Box 9120, Augusta, ME 04332-9120

The State Tax Assessor annually establishes the interest rate. The interest rate for calendar year 2005 is 0.667% per month; 8% per year, compounded

monthly.

The penalty for failure to file a return is the greater of $25 or 10% of the tax due. If the return is not filed within 30 days after the receipt of a demand

notice to file, the penalty is 100% of the tax due.

Office use only

The penalty for failure to pay a tax liability on time is 1%, up to a maximum of 25%, of the outstanding liability.

INS-7 Rev. 11/04