Form Lgt 140 - City, County, Or Urban County Government Insurance Premium Tax Annual Reconciliation Page 2
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1
2
3SECTION I (Continued)
Established
Premiums
Tax Payable
Collection Fee
Collected from
Additional Tax Due or
Tax Rate %
Collected
Retained
(Overpayment)
[(1) x (2)]
Policyholders
(1)
(2)
(4)
(6)
(3)
(5)
RD
3
QUARTER
Casualty
Fire & Allied Perils
Inland Marine
Life
Motor Vehicle
All Other Risks
Health (1)
(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line.
Credits
(Form LGT 142)
Total
TH
4
QUARTER
Casualty
Fire & Allied Perils
Inland Marine
Life
Motor Vehicle
All Other Risks
Health (1)
(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line.
Credits
(Form LGT 142)
Total
ANNUAL TOTALS
Casualty
Fire & Allied Perils
Inland Marine
Life
Motor Vehicle
All Other Risks
Health (1)
(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line of
Insurance.
Credits
(Form LGT 142)
Total
SECTION II - COMPUTATION OF ADDITIONAL PAYMENT DUE
(Do not complete if no additional tax is due for any quarter.)
Quarter
Tax Balance Due
Annual Interest Rate
Interest Due
Total Tax and
Date Tax
Interest Due
Was Paid
1st
nd
2
3rd
4th
Total
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