Installment Tax Reports And Payments - Arizona Department Of Insurance
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1Department of Insurance
INSTALLMENT TAX REPORT
State of Arizona
Reset
YEAR: ______
Financial Affairs Division – Tax Unit
2910 North 44th Street, Suite 210
ORIGINAL REPORT
TC 01
Phoenix, AZ 85018-7269
Telephone: (602) 364-3246
SUPPLEMENTAL REPORT
TC 02
Facsimile: (602) 364-3989
INSTALLMENT TAX REPORTS AND PAYMENTS
You must pay SIX Installment Tax payments if your net annual tax liability was $2,000 or more. Your net
annual tax liability is identified on your annual tax report by the phrase “Installment Tax Base”. Each
Installment Tax payment must equal 15% of the Installment Tax Base amount.
DO NOT FILE REPORTS OR PAY INSTALLMENT TAX IF LINE 1 BELOW IS LESS THAN $2,000
TO DETERMINE IF YOU MUST PAY INSTALLMENT TAX:
Enter the amount from your annual tax report that appears above the phrase
1.
“Installment Tax Base”
$
IF LINE 1 above is $2,000 OR MORE the result equals 15% of Line 1.
2.
0.00
You must pay this amount by each Due Date shown below.
$
COMPANY:
NAIC#:
DOMICILE:
PREPARER :
TITLE:
PHONE:
FAX:
E-MAIL:
CHECK BOX
(a)
(b)
(c)
(d)
FOR EACH
PAYMENT
PENALTY AND
PAYMENT
INSTALLMENT
Period
Pay
AMOUNT DUE
INTEREST
TOTAL AMOUNT
WITH THIS
DUE DATE
Code
Code
FROM LINE 2
SEE BELOW
DUE
REPORT
ABOVE
Pay code 26
0.00
0.00
1
March 15
19
0.00
0.00
2
April 15
20
0.00
0.00
3
May 15
21
0.00
0.00
4
June 15
22
0.00
0.00
5
July 15
23
0.00
0.00
6
August 15
24
PAY THIS AMOUNT
0.00
PENALTY AND INTEREST FOR LATE TAX PAYMENT
If your payment is late, you may include penalty and interest in column c.
The penalty amount is 5% of the tax paid late, but not less than $25.
Interest is 1% of the tax paid late, per month.
ELECTRONIC PAYMENT OPTION
You can electronically file tax reports and pay taxes via the NAIC OPTins system.
Visit
or call (816) 783-8990 for assistance.
TO PAY BY CHECK
Mail this report with your check payable to Arizona Department of Insurance to the address shown above.
E-INSTALLMENT TAX (R
. 11/09)
P
1
1
EV
AGE
OF
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