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Foreign And Domestic Insurance Entities (Legal Reserve Mutual) Form - Arkansas Secretary Of State

Charlie Daniels, Arkansas Secretary of State

Franchise Tax Report, 2004 Reporting Year

Annual Report as of December 31, 2003

FOREIGN AND DOMESTIC INSURANCE ENTITIES

(LEGAL RESERVE MUTUAL)

Reports and Taxes due on or before June 1, 2004. Substantial additional amounts due for reports with United States

Postal Services postmark after deadline. Reports may be filed over the Internet @

Report must be completed and signed in INK.

For Official Use Only

If tax contact information has changed, please correct below:

Phone # of tax contact: ________________

Federal Tax ID# _____________________

Date of Arkansas Affiliation: __________________________________

PRINCIPAL ARKANSAS OFFICE ADDRESS:

____________________________________________________________

(Street Address, City, State, Zip)

____________________________________________________________

ASSETS per Balance Sheet dated December 31, 2003

If the assets of the entity total less than $100,000,000 the tax is $100. If the assets of the

entity total $100,000,000 or more the tax is $200.

TOTAL DUE

State of __________________ County of ________________________________________

I declare, under penalties of perjury, that the above is true and correct, as reflected in the

books of the above named entity as of December 31, 2003.

Filed this _____day of __________ , ____ . Signature _____________________________

(Day)

(Month)

(Year)

Must be signed in ink by: Pres., Vice-Pres., Sec., Treasurer or Controller

Due on or before June 1, 2004 -Substantial penalties due after June 1, 2004

Remittance must accompany this report and must be written and signed in ink.

Checks Payable to Arkansas Secretary of State • Phone (501)-682-3409 or 1-888-233-0325

Business and Commercial Services Division • P.O. Box 8014 • Little Rock, Arkansas 72203-8014

You may file this electronically over the Internet @

Foreign And Domestic Insurance Entities (Legal Reserve Mutual) Form - Arkansas Secretary Of State