2011 Form Aid Ac Ci-T - Annual Report Of Premiums, Taxes, And Fees Of All Captive Insurance Companies - Arkansas Insurance Department Page 4

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COMPANY NAME__________________________________
2011 FORM AID AC CI-T
B.
CREDITS:
0.00
4. Affordable Neighborhood Housing Credit
$(___________________)
0.00
5. Low Income Housing Tax Credit
$(___________________)
0.00
6. SUBTOTAL A(3) LESS B(4,5)
$____________________
0.00
7. Capital Development Corporation Tax Credit
$(___________________)
0.00
8. Coal Mining Enterprise Credit
$(___________________)
0.00
9. Equity Investment Incentive Tax Credit
$(___________________)
0.00
10. NET PREMIUM TAX
$_________________
AMOUNT CANNOT BE LESS THAN ZERO
C. PRODUCERS REINSURANCE CAPTIVES:
If a producer reinsurance captive qualifies for tax exemption under ACA 23-63-1614(i), complete the
following and proceed to Section D (12)
Calculation of Investment Tax Exemption for Producers Reinsurance Captives:
0.00
(1) Qualified Certificate of Deposits: (ATTACH LIST)
$______________
0.00
(2) Bonds, Notes Warrants, or Other Securities Not In Default:
$______________
State (ATTACH LIST)
County, Incorporated City or Town, Duly Organized School District or
Other Taxing District of the State: (ATTACH LIST)
Local Improvement Districts in Arkansas: (ATTACH LIST)
0.00
(3) TOTAL ASSESTS AS OF 12/31/11 (1 + 2)
$_______________
D. CALCULATION OF NET PAYMENT DUE:
0.00
11. Net Premium Tax
$____________________
12. Fees
$
300.00
300.00
13. NET PAYMENT DUE (lines 11 + 12)
$____________________
MAKE CHECK PAYABLE TO STATE TREASURER OF ARKANSAS AND ATTACH TO FORM.
Page 2 of 3
Revised 2011

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