Form Ld-T - Annual Report Of Premiums,taxes And Fees Of Foreign Life And Accident And Health Insurance Companies - 2011 Page 7

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NAIC_______ COMPANY NAME__________________________________
2011 FORM AID AC LD-T
BASED ON SECTION C , LINE 5 , MARK THE BOX WITH THE GREATER AMOUNT BELOW:
X
COLUMN 1 - ARKANSAS
COLUMN 2 - STATE OF DOMICILE
USING THE AMOUNT FROM THE COLUMN MARKED ABOVE, COMPLETE THE FOLLOWING:
0.00
D. SECTION A LINE 3, Enter the amount here
$___________________*
E. CREDITS CANNOT BE TAKEN AGAINST FEES
0.00
6.
Arkansas Guaranty Fund Assessment Credit
$(___________________)
0.00
7.
Arkansas Comprehensive Health Ins. Pool (CHIP) Credit
$(___________________)
0.00
8.
Affordable Neighborhood Housing Credit
$(___________________)
0.00
9.
Low Income Housing Tax Credit
$(___________________)
0.00
10. a.
Credit for Arkansas Salaries not to exceed 70% of Line 1c.
$(___________________)
0.00
10. b. Credit for Arkansas Salaries not to exceed 80% of Line 2f.
$(___________________)
0.00
11.
Delta Geotourism Incentive Credit
$(___________________)
0.00
12.
AR Historic Rehab Income Tax Credit
$(___________________)
0.00
13.
SUBTOTAL (D less 6-12)
$____________________
0.00
14.
Capital Development Corporation Tax Credit
$(___________________)
0.00
15.
Coal Mining Enterprise Credit
$(___________________)
0.00
16.
Equity Investment Incentive Tax Credit
$(___________________)
F.
NET PAYMENT DUE
0.00
17.
Total Premium Tax Due (Figure cannot be less than zero)
$___________________
(E13 less 14-16)
150.00
18.
Total amount of Fees from Section B, based on Section D
$___________________
0.00
19.
Deduct Prepayments, if any, from below then enter here.
$(__________________)
Quarters
Check #
Amount - Do Not Round
Amounts
0.00
0
19.a. First
$
0
0.00
19.b. Second
$
0.00
0
19.c. Third
$
150.00
20. Net Payment Calendar Year 2011 (F17 + 18 – 19)
$__________________
(CHECK MADE PAYABLE TO THE STATE TREASURER OF ARKANSAS)
ARKANSAS INSURANCE DEPARTMENT
Page 2 of 4
REVISED 2011

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