Form E-Ucldr - Financial Affairs Division Premium Tax Unit - Arizona Department Of Insurance
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2ARIZONA DEPARTMENT OF INSURANCE
FINANCIAL AFFAIRS DIVISION
PREMIUM TAX UNIT
2910 NORTH 44TH STREET, SECOND FLOOR
Phoenix, Arizona 85018-7256
Phone: (602) 912-8429/Fax: (602) 912-8421
For Office Use Only
For Audit Use Only
Complete Company Name and Home Office Address
State of Incorporation
X
X
ARIZONA
X
Arizona Company Number:
X
Federal I. D. Number:
X
Preparer’s Name and Title:
E-Mail Address:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
Summary of Annual Fees Due August 1, 2004 if the Reinsurer's fiscal year end is December 31st
or November 1, 2004 if the Reinsurer's fiscal year ends on a date other than December 31st.
$
1)
Certificate of Authority Renewal Fee
4,500.00
(Pay Code 57)
$
2)
Annual Statement Filing Fee
300.00
(Pay Code 28)
$
3)
TOTAL DUE:
4,800.00
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AKE CHECK PAYABLE TO AND
Attention: TAX UNIT
M
:
2910 North 44
Street, Second Floor
AIL CHECK WITH REPORT TO
th
Phoenix, Arizona 85018-7256
It is hereby certified that the Domestic Unaffiliated Credit Life & Disability Reinsurer named above did not write direct premiums in the state of Arizona
during 2003 and does not owe premium taxes prescribed by A.R.S. § 20-224.
PREPARER CERTIFICATION
COMPANY OFFICER CERTIFICATION
I certify that I have prepared this report. It is true, complete and correct to the
I certify that I have examined this report. It is true, complete and correct to the best
best of my knowledge.
of my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
FAILURE TO FILE AN ANNUAL STATEMENT OR PAY FEES:
E-UCLDR (R
. 6/04)
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OF
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