Form E-Qtr2 - Estimated Tax Computation Page 3

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#4
Code 79
DEPARTMENT OF INSURANCE
AHCCCS Contractor
STATE OF ARIZONA
Quarterly Premium Tax Report
4
Quarter - Due December 15
th
th
Financial Affairs Division
PREMIUM TAX UNIT
2910 NORTH 44TH STREET, SECOND FLOOR
PHOENIX, AZ 85018-7256
PHONE: (602) 912-8429 FAX: (602) 912-8421
AHCCCS Contractor’s Complete Name
Federal I.D. Number
Instructions: An AHCCCS Contractor is required to file this report and pay its estimated premium tax pursuant to A.R.S. §§ 36-2905 and 36-2944.01
on or before December 15th. See Form E-QTR.INSTRUCTION for further assistance with quarterly reporting and payment requirements.
ESTIMATED TAX COMPUTATION
Enter the AHCCCS Plan I.D. Number and estimated amount of total capitation, including reinsurance and any other reimbursement paid to the
1)
Contractor by the Arizona Health Care Cost Containment System from October 1 through December 31 for each Plan Type.
AHCCCS Plan Types
Plan I.D. Number
Estimated Amounts
Acute Care
$
AC
VD
Ventilator Dependent
$
Elderly & Physically Disabled
$
EPD
TOTAL
$
QT4
2)
Premium Tax Due: Enter 2% of the TOTAL from line 1............................................................................................. $
[79]
If Premium Tax Due is paid in full by December 15
, enter 0 (Zero) on line 6 and go to line 7, otherwise complete lines 3 through 6
th
CIVIL PENALTY AND INTEREST COMPUTATION
If Premium Tax Due is paid after December 15th, complete lines 3 through 6
3)
Late Payment Penalty: Enter 5% of the amount on line 2 or $25.00, whichever is greater............................................................$
4)
Interest Rate: From the table below, enter the rate of interest based upon the late payment date.................................................
%
December 16 - January 15 1%
January 16 – February 15 2%
February 16 or later: Increase rate of interest 1% for each additional month
5)
Interest Amount Due: Multiply line 2 times line 4 ...........................................................................................................................$
6)
Total Penalty and Interest Due: Add lines 3 and 5 ........................................................................................................................$
« [26]
7)
Total Payment Due: Add lines 2 and 6 ...........................................................................................................................................$
8)
Adjustment for Previous Quarter Ending September 30
th
: (See Instruction Form E-QTR ) ......................................................$
[78]
9)
Total Payment Enclosed: Add lines 7 and 8 ..................................................................................................................................$
Please enter your check / draft number here:
Make check payable to Arizona Department of Insurance
Type Preparer’s Name and Title
Preparer’s Signature and Date
Toll free or collect phone number
Fax number
E-Mail Address
Mail this report form with check to the address listed above
E-QTR4 (R
. 11/03)
P
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1
EV
AGE
OF

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