Form 800es - Virginia Insurance Premiums License Tax Estimated Payment Voucher - 2017 Page 3
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2
3
42017 ESTIMATED TAX PAYMENT RECORD
CHECK OR MONEY
AMOUNT OF CREDIT
TOTAL AMOUNT
DATE
AMOUNT
ORDER NO.
APPLIED
PAID
PAYMENT MADE
$
$
$
00
00
00
WITH DECLARATION
00
00
00
$
$
$
SECOND PAYMENT
$
00
$
00
$
00
THIRD PAYMENT
$
00
$
00
$
00
FOURTH PAYMENT
00
00
00
$
$
$
TOTALS
Please cut along dashed lines below.
File Vouchers in Number Sequence
Order 1, 2, 3, 4.
Do not submit this entire page.
Virginia Insurance Premiums License Tax
2017
VOUCHER 2
Form 800ES
Estimated Payment Voucher
Due 6/15/2017
(DOC ID 800)
Virginia Department of Taxation
PO Box 26179, Richmond, VA 23260-6179
If you file electronically, do not
(804) 404-4163
Office Use
file this voucher.
/
/
0000000000000000 8008888 000000 02
39-
VA Account Number
2017
1. Taxable Year
Federal Employer’s ID Number
NAIC/License #
Company Name
2. Estimated tax
.
00
for the year ...... $
Address (Number and Street)
3. Amount of this
v
.
00
payment ........... $
City, State and ZIP Code
— Do not write below this line. —
I declare that this declaration has been examined by me and to the best of my knowledge and belief, is true, correct and complete.
Signature
Date
Phone
Virginia Insurance Premiums License Tax
2017
Form 800ES
VOUCHER 1
Estimated Payment Voucher
(DOC ID 800)
Due 4/15/2017
Virginia Department of Taxation
PO Box 26179, Richmond, VA 23260-6179
If you file electronically, do not
(804) 404-4163
file this voucher.
Office Use
/
/
0000000000000000 8008888 000000 01
39-
2017
VA Account Number
1. Taxable Year
Federal Employer’s ID Number
NAIC/License #
2. Estimated tax
Company Name
.
00
for the year ...... $
Address (Number and Street)
3. Amount of this
v
.
00
payment ........... $
City, State and ZIP Code
— Do not write below this line. —
I declare that this declaration has been examined by me and to the best of my knowledge and belief, is true, correct and complete.
Page 3
Signature
Date
Phone
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