Claim For Refund Of Premium Taxes - South Dakota Division Of Insurance Form

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SOUTH DAKOTA DIVISION OF INSURANCE
ND
124 S. EUCLID AVENUE, 2
FLOOR
PIERRE SD 57501
605-773-3563
CLAIM FORM
FOR REFUND OF PREMIUM TAXES
YEAR ENDING: _________
Company Name: _______________________________________________________________
Contact Person: _______________________________ Telephone: _____________________
NAIC # _____________________________
FEIN # ________________________________
Date: _______________________________
Refund check should be mailed to the following address:
______________________________________________________________________________
MAILING ADDRESS
______________________________________________________________________________
CITY
STATE
ZIP
In accordance with SDCL 10-44-2, I hereby request a refund for the overpayment of premium
taxes paid to the state of South Dakota for the period ending ____________________________.
Amount of taxes paid: _________________________
This claim is being made for the amount of _____________________. Give a brief summary of
the basis for this claim.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________ .
________________________________________________
________________________
SIGNATURE OF OFFICER AUTHORIZED TO MAKE SUCH CLAIM
TITLE
________________________________________
DATE
Subscribed and sworn to before me, a Notary Public in and for the state
of ___________________________ , county of __________________
this ______________ day of ___________________ , ____________ .
____________________________________
NOTARY SIGNATURE
(SEAL)
____________________________________
COMMISSION EXPIRES
TAXREFUND/02-04

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