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4588, Page 2

FEIN or TR Number

Foreign and alien insurers complete lines 30 through 46. Domestic insurers, go to line 47.

TAXES

A — State of Incorporation

B — Michigan

X X X X X X X X

30. State of incorporation tax.......................................................................

30.

X X X X X X X X

31. Tax Liability from line 29 ........................................................................

31.

FEES AND ASSESSMENTS

32. Annual statement filing fee ....................................................................

32.

X X X X X X X X

33. Certificate of Authority renewal fee ........................................................

33.

X X X X X X X X

34. Certificate of Compliance ......................................................................

34.

X X X X X X X X

35. Certificate of Deposit .............................................................................

35.

X X X X X X X X

36. Certificate of Valuation ...........................................................................

36.

37. Enter total of other fees paid in the state of incorporation.

Attach a detailed schedule of fees........................................................

37.

X X X X X X X X

38. Fire Marshall Tax ...................................................................................

38.

39. Second Injury Fund ...............................................................................

39.

40. Silicosis and Dust Disease Fund ...........................................................

40.

41. Safety Education and Training Fund .....................................................

41.

42. Total of all other assessments. Attach schedule of assessments .........

42.

TOTAL

43. Add lines 30 through 42 .............................................................................

43.

X X X X X X X X

44. Accelerated and Certificated Refundable Credits (see instructions) .....

44.

45. Total Taxes, Fees and Assessments. Subtract line 44 from line 43 .......

45.

46. Retaliatory Amount. Subtract line 45, column B, from column A. If less than zero, enter zero...............................

46.

47. Total MBT Tax Liability. Add lines 29 and 46. Domestic insurers, enter amount from line 29 .............................

47.

PAYMENTS, REFUNDABLE CREDITS AND TAX DUE

48. Overpayment credited from prior MBT return .........................................................................................................

48.

49. Estimated tax payments .........................................................................................................................................

49.

50. Flow-Through Withholding payments .....................................................................................................................

50.

51. Tax paid with request for extension ........................................................................................................................

51.

52. Refundable Credits (see instructions) ....................................................................................................................

52.

53. Total Payments. Add lines 48 through 52. (If not amending, then skip to line 55.) ................................................

53.

a. Payment made with the original return ................................. 54a.

AMENDED

54.

RETURN

b. Overpayment received on the original return ....................... 54b.

ONLY

c. Add lines 53 and 54a and subtract line 54b from the sum ... .................................................... 54c.

55. TAX DUE. Subtract line 53 (or line 54c, if amending) from line 47. If less than zero, leave blank .........................

55.

56. Underpaid estimate penalty and interest from Form 4582, line 38. ........................................................................

56.

% =

57. Annual return penalty (a)

(b)

plus interest of (c)

. Total ....... 57d.

58. PAYMENT DUE. If line 55 is blank, go to line 59. Otherwise add lines 55, 56 and 57d .........................................

58.

OVERPAYMENT, REFUND OR CREDIT FORWARD

59. Overpayment. Subtract lines 47, 56 and 57d from line 53 (or line 54c, if amending).

If less than zero, leave blank (see instructions).....................................................................................................

59.

60. CREDIT FORWARD. Amount on line 59 to be credited forward and used as an estimate for next MBT tax year ....

60.

61. REFUND. Amount on line 59 to be refunded..........................................................................................................

61.

Taxpayer Certification.

Preparer Certification.

I declare under penalty of perjury that the information in

I declare under penalty of perjury that this

this return and attachments is true and complete to the best of my knowledge.

return is based on all information of which I have any knowledge.

Preparer’s PTIN, FEIN or SSN

By checking this box, I authorize Treasury to discuss my return with my preparer.

Authorized Signature for Tax Matters

Preparer’s Business Name (print or type)

Authorized Signer’s Name (print or type)