Retaliatory Tax Calculation For Non-Domestic Legal Expense Organizations - Oregon Department Of Consumer And Business Services
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1STATE OF OREGON
Department of Consumer and Business Services
Insurance Division
Retaliatory Tax Calculation
For Non-Domestic Legal Expense Organizations
Year ending Dec. 31,
Name
State of domicile
Certificate of authority number
Mailing address
City
State
ZIP code
Federal employer ID number
Contact person
Phone number
E-mail
Name or address change
This is an amended return
Realiatory Tax
per ORS 750.705 and ORS 731.854
HOME STATE BASIS:
1. Annual or continuation fee
2. Filing annual statement
3. Agent appointment fees paid by insurer
4. State fraud fees or assessments
5. Other fees:
6. Other fees:
7. Total fees (add Lines 1 through 6)
8. Premium or privilege tax
X
%
9. Income or excise tax
10. Other taxes:
11. Other taxes:
12. Total taxes (add Lines 8 through 11)
13. Total Home State Basis (add Lines 7 and 12)
OREGON BASIS:
14. Oregon Corporation Excise Tax (Form 20-INS, Line 29)
estimated
15. Certificate of Authority renewal fee (paid on anniversary of registration)
$350
16. Total Oregon Basis (add Lines 14 and 15)
$350
17. Retaliatory Tax (Line 13 minus Line 16. If negative, enter -0-)
Return completed forms to:
Our street address is:
Oregon Insurance Division – 4
Oregon Insurance Division – 4
P.O. Box 14480
350 Winter Street NE, 3rd floor
Salem, OR 97309-0405
Salem, OR 97301-3883
This form need to be filed by non-domestic legal expense organizations registered in Oregon.
Filing Due Dates
Retaliator Tax Calculation for Non-domestic Legal Expense Organizations: April 1. Postmark is accepted as the filing date.
Checks: should be made out to Department of Consumer and Business Services
Internet address: Blank forms are available on the Web site.
Questions on renewals and other required filings:
Finacial Regulation
503-947-7982
Questions on retaliatory tax:
Lynette Hadley, insurance tax analyst
OR
Shannon O’Shea, insurance tax analyst
503-947-7046
503-947-7218
lynette.m.hadley@state.or.us
shannon.oshea@state.or.us
440-4879 (2/10/COM/WEB)
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