Annual Tax Return - Nebraska Department Of Insurance - 2011

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STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
ANNUAL TAX RETURN FOR YEAR ENDING DECEMBER 31, 2011
Foreign/Alien Title Insurers
Must be attached to the tax return:
Mail tax return and check to:
Nebraska Department of Insurance
NE Business Page of the 2011 Annual Statement
P. O. Box 82089
Schedule T of the 2011 Annual Statement
Lincoln, NE 68501-2089
Check made payable to Nebraska Dept. of Insurance
COMPANY INFORMATION
Nebraska Co. I.D. No.
Contact Person
NAIC No.
E-Mail Address
Federal Tax I.D. No.
Telephone
Company Name
Street Address
City
State
Zip Code
Organized Under the Laws of
SECTION I - SIGNATURE OF FISCAL OFFICER OF COMPANY
State of
)
)ss
County of
)
I,
being duly sworn on oath say that I am
,
of the
Insurance Company of the State of
and that the tax statement is correctly computed in accordance with the foregoing instructions.
(Signature)
Subscribed and sworn to before me, a Notary Public, this
day of
20
(Notary Public)
FOR TITLE P/C 2011
1

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