Annual Foreign And Domestic Insurance Entities Franchise Tax Report 2012 (Legal Reserve Mutual) Form printable pdf download

Annual Foreign And Domestic Insurance Entities Franchise Tax Report 2012 (Legal Reserve Mutual) Form

123456789

Mark Martin

, Arkansas Secretary of State

ANNUAL FOREIGN AND DOMESTIC INSURANCE ENTITIES

FRANCHISE TAX REPORT 2012 (Legal Reserve Mutual)

For the year ending 12/31/2011

Reports and taxes are due on or before May 1, 2012. Penalty and interest will be due for reports if the United States Postal Service’s

postmark is after the deadline. Complete this report online at , or sign in ink and mail to the address

listed below.

Save Time & File Online

Anytime Day Or Night At

Correct any information, if needed, in space provided below:

Tax Contact Name:

Address:

Address Line 2:

City, State, Zip:

Phone # of Tax Contact:

E-mail Address:

Required Information:

Federal Tax ID#:

Date of Arkansas Affiliation:

___ A

4, 5, 6 & 7

LL OF THE INFORMATION IN SECTIONS

HAS BEEN VERIFIED AND HAS BEEN FOUND TO BE

’

EXACTLY THE SAME AS LAST YEAR

S REPORT

Principal Arkansas Office Address:

Street Address:

Address 2:

City, State, Zip:

State of: ___________________________

____

County of: _____________________________

31, 2011

SSETS PER BALANCE SHEET DATED

ECEMBER

NOTE: If the assets of the entity total less than $100,000,000, the tax is $300. If the assets for the entity

total $100,000,000 or more, the tax is $400.

OTAL DUE

I declare, under the penalties of perjury, that the foregoing statements are true to the best of my knowledge and belief.

Executed this _________ day of __________________, ____________

(Day)

(Month)

(Year)

Print Name________________________________________

Signature________________________________________

Must be printed in ink by: Pres., Sec., Vice-Pres., Treasurer, or Tax Preparer

Must be signed in ink by: Pres., Sec., Vice-Pres., Treasurer, or Tax Preparer

Due on or before May 1, 2012 – Penalty and interest due after May 1, 2012

You may file this electronically over the internet at

Remittance must accompany this report • Make checks payable to Arkansas Secretary of State

Phone 501-682-3409 or 888-233-0325 (Toll Free)

Mail to: Business and Commercial Services Division • P.O. Box 8014 • Little Rock, Arkansas 72203-8014

Annual Foreign And Domestic Insurance Entities Franchise Tax Report 2012 (Legal Reserve Mutual) Form

Related Articles

Related forms

Related Categories