Form Pt-01(A) - Annual Insurance Premium Tax Return - 2002 Page 2
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4Nevada Department of Taxation
SCHEDULE 1
STATEMENT OF PREMIUM TAX AND FEES ON RETALIATORY BASIS
For Year Ending December 31, 2002
(A)
(B)
NEVADA BASIS
STATE OF INC
1. Gross Annual Premiums/Considerations (See Instructions)(Do not include Industrial Insurance)
2. Plus: Current dividends applied to provide paid-up additions or to reduce endowments or
premium-paying periods
Less: Deductions, categorized by class of business according to applicable tax rate as necessary
3. Dividends paid or credited to policy holders
4. Net premiums or considerations received from policies or contracts issued in connection with plans
qualified or exempt under Sections 401, 403, 404 or 501 of U.S. Internal Revenue Code
5. Other
(Itemize)
6. Net Taxable Premiums (Line 1 plus Line 2 less Lines 3, 4 and 5)
7. Taxes Payable (according to applicable tax rate. Tax rate for Nevada is 3.5%)
Lines 8 through 11, Additional Taxes and Assessments
(Include Fire Marshal, Ocean Marine and/or other state or municipal tax that is levied on a Nevada
company doing business in your state)
$
@
%
8.
$
@
%
9.
$
@
%
10.
$
@
%
11.
12. Total Taxes (Lines 7 through 11)
The fees listed below are for retaliatory calculation purposes only. DO NOT REMIT THESE FEES TO THE DEPARTMENT OF
TAXATION.
13. Filing Annual Statement
$25
14. Annual Licensing Fee (Nevada $2,450)
15. Filing Charter Documents (Nevada $10 each)
16. Filing Power of Attorney (Nevada $5)
17. Filing any other certificate form (Nevada $10 each)
18. Filing Certificate of Compliance (Nevada -0-)
19. Agent Licenses: Resident Appointments _______@ $15 each
Non Resident Appointments _______@ $15 each
20. Filing Rates and Forms _______@ $25 each
21. Filing Riders and Endorsements _______@ $10 each
22. Total all Fees/Charges (Lines 13 through 21)
23. Total Taxes and Fees (Line 12 and Line 22)
24. Retaliatory Assessment (Line 23, Column B minus Line 23, Column A)
(Remit Retaliatory Assessment to the Department of Taxation)
PT-01(B)
Revised 12-23-02
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