Form 4905 - Insurance Company Annual Return For Corporate Income And Retaliatory Taxes - 2012

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Michigan Department of Treasury
4905 (Rev. 07-12), Page 1
This form cannot be used as
an amended return; see the
2012 Insurance Company Annual Return for
Amended Insurance Company
Annual Return (Form 4906).
Corporate Income and Retaliatory Taxes
Issued under authority of Public Act 38 of 2011.
1. Company Name
2. Federal Employer Identification Number (FEIN)
Address (Number, Street)
3.
Check if Foreign Insurer
City
State
ZIP/Postal Code
Country Code 4. State of Incorporation (use 2 letter abbreviation)
GROSS DIRECT PREMIUMS WRITTEN IN MICHIGAN
00
5. Gross direct premiums written in Michigan.............................................................................................................
5.
00
6. Premiums on policies not taken.......................................................................
6.
00
7. Returned premiums on canceled policies........................................................
7.
00
8. Receipts on sales of annuities .........................................................................
8.
00
9. Receipts on reinsurance assumed (see instructions) ......................................
9.
00
10. Add lines 6 through 9.............................................................................................................................................. 10.
00
11. Direct Premiums Written in Michigan. Subtract line 10 from line 5. If less than zero, enter zero .....................
11.
DISABILITY INSURANCE EXEMPTION
12. Disability insurance premiums written in Michigan, not including credit or disability income insurance premiums,
00
OR $190,000,000, whichever is less ......................................................................................................................
12.
13. Gross direct premiums from all lines of insurance carrier services
00
received everywhere ....................................................................................
13.
280,000,000
00
14. Phase out ........................................................................................................ 14.
00
15. Subtract line 14 from line 13. If less than zero, enter zero ............................. 15.
00
16. Exemption reduction. Multiply line 15 by 2 ............................................................................................................. 16.
00
17. Subtract line 16 from line 12. If less than zero, enter zero ..................................................................................... 17.
00
18. Adjusted Tax Base. Subtract line 17 from line 11 ................................................................................................... 18.
00
19. Corporate Income Tax Before Credits. Multiply line 18 by 1.25% (0.0125) ........................................................ 19.
CREDITS
20. Enter amounts paid from 1/1/2011 to 12/31/2011 to each of the following
00
a. Michigan Workers’ Compensation Placement Facility .............................. 20a.
00
b. Michigan Basic Property Insurance Association ....................................... 20b.
00
c. Michigan Automobile Insurance Placement Facility ................................. 20c.
00
d. Property and Casualty Guaranty Association ........................................... 20d.
00
e. Michigan Life and Health Insurance Guaranty Association ...................... 20e.
00
21. Add lines 20a through 20e...................................................................................................................................... 21.
00
22. a. Michigan Examination Fees ..................................................................... 22a.
00
b. Credit. Multiply line 22a by 50% (0.50) ............................................................................................................ 22b.
00
23. Tax liability before recapture. Subtract lines 21 and 22b from line 19 .................................................................... 23.
00
24. Recapture. Enter amount from Form 4902, line 22 ................................................................................................ 24.
00
25. Total Michigan Tax. Add lines 23 and 24 .............................................................................................................. 25.
Return is due March 1, 2013.
WITHOUT PAYMENT: Mail return to:
WITH PAYMENT: Pay amount on
Make check payable to “State of
line 52 and mail check and return to:
Michigan.” Print taxpayer’s FEIN, the tax
Michigan Department of Treasury
year, and “CIT” on the front of the check.
Michigan Department of Treasury
PO Box 30803
Do not staple the check to the return.
PO Box 30804
Lansing MI 48909
Lansing MI 48909
+
0000 2012 38 01 27 6
Continue and sign on Page 2

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