Form Ins-5 - Fire Investigation And Prevention Tax

*033110100*

Form INS-5, Page 2

033110100

.00

Gross Direct Premiums or Assessments Subject To Tax (Enter amount from line 1) ................................................................ 2.

.00

3a.

Line 2 Multiplied by 0.014 ..................................................................................................................................................... 3a.

3b.

SPECIAL ASSESSMENT

.00

Amount of line 2 collected from 1/1/03 – 6/30/03:

x 0.006 = ............. 3b.

.00

Liability (3a plus 3b) ................................................................................................................................................................. 4.

.00

Less: Prior Payments ............................................................................................................................................................. 5.

.00

Balance Due (Line 4 minus line 5) ............................................................................................................................................. 6.

.00

Overpayment (Line 5 minus line 4) ............................................................................................................................................ 7.

.00

7a.

Applied to current monthly report, line 2 ............. 7a.

To be refunded ........ 7b.

Make check payable to Treasurer, State of Maine; send check and return to:

Maine Revenue Services

P.O.Box 1064

Augusta, ME 04332-1064

DATE _____________________________________________

*BY _____________________________________________

CONTACT PERSON _________________________________

TITLE ___________________________________________

TELEPHONE NUMBER ______________________________

*Must be signed by the President, Treasurer, Secretary, Chief Accounting Officer, or Attorney-in-fact of a Reciprocal Insurer.

INSTRUCTIONS

Column 1 must agree with column 1 of the Maine portion of your NAIC annual statement. Percentages for column 4 are taken from the

enclosed notice.

Line 3b – Special Assessment. This amount is .006 for January through June only.

The State Tax Assessor annually establishes the interest rate by rule. The interest rate for calendar year 2004 is 0.5% per month, compounded

monthly.

The penalty for failure to file a return is the greater of $25 or 10% of the tax due. If the return is not filed within 30 days after the receipt of a

demand notice to file, the penalty is 100% of the tax due.

The penalty for failure to pay a tax liability on time is 1%, up to a maximum of 25%, of the

outstanding liability.

Office use only