Form 115a - Tax On Premiums Paid To Unauthorized Insurers

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FORM 115A
FORM 115A
19
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PREMIUM TAX RETURN
TAX ON PREMIUMS PAID TO UNAUTHORIZED INSURERS
Please change
Name and/or
(For Department Use Only)
Address if shown
incorrectly at right
SCHEDULE OF INSURANCE PURCHASED FROM UNAUTHORIZED INSURERS
TOTAL
TOTAL AMOUNT ENCLOSED
DECLARATION:
FORM 115A Premium Tax Return
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