Form E-Rg - Foreign Risk Retention Group Annual Tax Report Page 4

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COMPANY NAME:
State Of Incorporation:
NAIC#:
YEAR:
School Tuition Organization (STO) Credits
ARS §§ 20-224.06 and 20-224.07
Complete this form only if you made contributions to School Tuition Organizations that were pre-
approved by the Arizona Department of Revenue. Application and Implementation forms are
available at
PART 1 – TUITION CREDITS (ARS § 20-224.06)
(a)
(b)
(c)
School Tuition Organization Name and Address
Credit
Contribution
Approval
Amount
Number
1
$
2
$
3
$
Total credit this calendar year…..Add lines 1-3
0.00
4
$
ST1
PART 2 – CREDITS FOR SCHOLARSHIPS FOR DISABLED/DISPLACED STUDENTS (ARS § 20-224.07)
(a)
(b)
(c)
School Tuition Organization Name and Address
Credit
Contribution
Approval
Amount
Number
1
$
2
$
3
$
0.00
Total credit this calendar year…..Add lines 1-3
ST2
$
4
PART 3 – CREDIT AMOUNTS USED AND CARRIED OVER FOR THIS CALENDAR YEAR
(d)
(e)
(a)
(b)
(c)
STO Credit
Carry Forward
Amount
Description
Reference
Used
Page 2, line 5
0.00
Gross Tax
1
Amounts
AZ Domestic Stock L/D
0
2
below will
Amounts
Insurer
N/A
appear in Page
below will
0
Enterprise Zone Credit
N/A
3
2, lines 8a and
carry forward*
8b
4
0.00
Line 1 minus lines 2 and 3, but not less than 0
0.00
0.00
0.00
SC1
5
Total Tuition Credits
Part 1, line 4 above
0.00
0.00
0.00
Credits for Scholarships
Part 2, line 4 above
SC2
6
*Amounts shown in Part 3, column (e) will be carried forward for a period of not more than 5 calendar
years
E-RG (11/09)
Arizona Department of Insurance
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