Annual Foreign And Domestic Insurance Entities Franchise Tax Report 2012 (Authorized Capital Stock) Form printable pdf download

Annual Foreign And Domestic Insurance Entities Franchise Tax Report 2012 (Authorized Capital Stock) Form

Mark Martin

123456789

, Arkansas Secretary of State

ANNUAL FOREIGN AND DOMESTIC INSURANCE ENTITIES

FRANCHISE TAX REPORT 2012 (Authorized Capital Stock)

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:

TOTAL AUTHORIZED CAPITAL STOCK

(See Instruction 13)

Tax Contact Name:

NUMBER OF SHARES

PAR VALUE EACH

Address:

Address Line 2:

City, State, Zip:

Phone # of Tax Contact:

NO PAR VALUE =$25 PER SHARE

E-mail Address:

Required Information:

ISSUED AND OUTSTANDING CAPITAL STOCK

Federal Tax ID#:

(See Instruction 14)

Date of Arkansas Affiliation:

NUMBER OF

PAR VALUE EACH

TOTAL

___ A

4, 5, 6, 7 &

LL OF THE INFORMATION IN SECTIONS

X $

= $

HAS BEEN VERIFIED AND HAS BEEN FOUND TO BE

X $

= $

’

EXACTLY THE SAME AS LAST YEAR

S REPORT

X $

= $

No PV=$25 per share

(Add 7a +7b + 7c) TOTAL:

= $

Principal Arkansas Office Address:

Street Address:

Address 2:

City, State, Zip:

State of: ___________________________

____

County of: _____________________________

NOTE: The Franchise Tax is based on the Issued and Outstanding Capital Stock per the TOTAL. If the

total is less than $500,000, the tax is $300. If the total is $500,000 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 (Authorized Capital Stock) Form

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