Form Mo 375-0429 - Chapter 380 Missouri Mutual Companies - 2013
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missouri insurance taxes for calendar year 2013
due march 1, 2014
CHAPTER 380 MISSOURI MUTUAL COMPANIES
missouri department of insurance,
financial institutions and professional registration
p.o. box 690
Jefferson city, missouri 65102-0690
name of company
mailing address
contact person
telephone number
e-mail address
naic number (group-company) or difp number
INSTRUCTIONS
tax returns are due march 1. no authority exists for granting extensions of time for filing the annual premium tax return, or for making
payment of any of the quarterly tax assessments. only one copy of the return needs to be filed with the missouri department of
insurance, financial institutions, and professional registration at p.o. box 690, Jefferson city, mo 65102-0690. be sure you have
included your 9-digit naic number on the premium tax return and on ALL quarterly assessment forms. DO NOT file a copy of this
return with the Missouri Department of Revenue.
DO NOT send payment with this tax return. the march 1 quarterly payment for 2014 should be sent to the missouri department of
revenue, at p.o. box 898, Jefferson city, mo 65105-0898 along with a copy of your completed march assessment form. a blank copy
of the march assessment form will be sent to your company electronically in december. the June 1, september 1, and december 1
assessments will be sent to you electronically at least a month before the due date. the 2013 annual tax reconciling payment will be
included on your June 2014 assessment. DO NOT make a payment of the remainder of your 2013 annual tax until you receive the
June assessment. Only use the quarterly assessment forms that are provided by the State of Missouri.
claims for refund of overpayment of tax must be filed with the missouri department of revenue pursuant to 136.035 rsmo.
see page 3 of this return for a checklist of necessary items to be included with this return. for frequently asked questions or forms, go
to our website at see industry/forms/tax forms. if you have any questions concerning this premium tax return,
please call 573-526-4986, 573-751-1929 or 573-526-1589.
THE FOLLOWING SECTION IS REQUIRED TO BE COMPLETED AND NOTARIZED
name of president
name of secretary
being duly sworn, on oath say that they are the president and the secretary, respectively of the ___________________________
__________________________________________________________________________________________________ and that the
attached is a true, full and correct statement of missouri direct premiums received during the year of 2013 and include all policies and premiums
wherever written covering property and interest in the state of missouri without deductions except as therein set forth and the amount of all
taxes, license fees, assessments and all other obligations due and/or paid to the respective states, and of missouri credits for the stated year.
signature of president
signature of secretary
county (or city of st. louis)
state of
notary public embosser or
black ink rubber stamp seal
subscribed and sworn before me, this
USE RUBBER STAMP IN CLEAR AREA BELOW.
day of
year
notary public signature
my commission
expires
notary public name (typed or printed)
PAGE 1
mo 375-0429 (11-13)
ex
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