Form B - Premium Tax Return Other Than Life Companies - 2013 Page 2

RECAPITULATION

Page 2

Col. 1

Col. 2

ALL OTHER REQUIREMENTS AND OBLIGATIONS

State of Incorporation

State of Iowa

(Non-Iowa Companies Only)

Basis

Basis

13.

$

$

14

15.

16.

17.

Totals

$

$

TOTAL AGGREGATE LIABILITY

18. Fees, taxes and other (Total Item 11 from application for renewal of Certificate of

$

$

Authority, Items 12 and 17 from this premium tax return)

GREATER OF TOTAL AGGREGATE LIABILITY

$

19. Enter the greater of Column 1 or 2 from line 18.

LESS CREDITS

20. Enter the amount already paid from Item 12 of application for renewal of

$

Certificate of Authority.

$

21. Enter the amount already paid to Iowa from Item 17.

22. Miscellaneous credits, attach all supporting documentation.

23. Credit balance from line 26 of 2012 tax return.

24. Premium tax prepayment credit (enter amounts

paid

with the June 1st and

August 15th prepayment statements, do not enter any credit balances from prior year.)

$

25. Total (Items 20, 21, 22, 23, 24)

BALANCE DUE

$

26.

Net taxes and retaliatory fees now due (Item 19 less 25)

THE AMOUNT OF TAXES AND FEES DUE IS THE TOTAL ON LINE 26. ATTACH CHECK TO THE FRONT OF THE

RETURN.

IF A NEGATIVE AMOUNT RESULTS, IT MAY BE APPLIED AS A CARRY FORWARD CREDIT IN ACCORDANCE WITH

CHAPTERS 432 AND 505, CODE OF IOWA [Sections 432.1 and 505.11].

State of . . . . . . . . . . . . . . . . . . . . . .

ss:

County of . . . . . . . . . . . . . . . . . . . .

I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . being first duly sworn, say and depose on oath, that I am the

_____President _____ Vice-President _____Secretary _____Attorney-in-Fact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .of the

(strike inapplicable words)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

that I am familiar with the subject matter reported in the foregoing return, and that the amounts set forth therein are correct to the best of my information,

knowledge and belief.

(Corporate Seal)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

President

Vice-President

Sec’y

Atty-in-Fact

Contact Person, Title and Phone Number

e-mail address

If Contact or e-mail information is changed from last year please check this box.