Form Pt-01 - Annual Insurance Premium Tax Return - 2004

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Nevada Department of Taxation
Company ID: New:___________________
DUE DATE MARCH 15, 2005
1550 E. College Parkway Rm. 115
Carson City NV 89706
Federal ID:__________________
Phone: (775) 684-2000
Fax: (775) 684-2020
Premium Tax:__________________
ANNUAL INSURANCE PREMIUM TAX RETURN 2004
Retaliatory Tax:__________________
DO NOT INCLUDE INDUSTRIAL INSURANCE (WORKERS COMPENSATION)
Total Remittance:__________________
DEPARTMENT USE ONLY
Amount ____________________________
Check No. __________________________
Date Rec'd __________________________
Initials ______________________________
(A)
(B)
Net Quarterly Taxable Premiums/Considerations
REPORTED
ACTUAL
1
1. March 31, 2004
2. June 30, 2004
2
3. September 30, 2004
3
4. December 31, 2004
4
5. Total Premiums/Considerations (Add Lines 1 through 4)
5
6. Total Premiums/Considerations (Line 5, Column B - Must agree with Schedule 1, Line 6A)
6
7. Gross Premium Tax (3.5% of Line 6 - Must agree with Schedule 1, Line 12A)
7
8. Home Office Credit, if qualified (N.R.S. 680B.050) (Form PT-04 and required documents must be attached)
8
(
)
9. Net Premium Tax Due for Calendar Year 2004 (Line 7 less Line 8)
9
10. Life/Health Guaranty Association Offset (N.R.S. 686C)
10
11. Property/Casualty Guaranty Association Credit (N.R.S. 687A)
11
12. Total Cash Payments made with Quarterly Returns (DO NOT INCLUDE ANY PENALTY AND/OR INTEREST)
12
(
)
13. Total Overpayment carried forward from 2003 (See PT-01, Line 19 of 2003)
13
14. Total Overpayment refunded by Nevada in 2004
14
(
)
15. Overpayment Remaining (Line 13 minus Line 14)
15
(
)
16. Net Premium Tax Due
16
17. Penalty 10% or .10 of Line 16 (If postmarked after due date)
17
18. Interest 1.5% or .015 of Line 16 (If postmarked after due date, for each month or fraction of a month past due)
18
19. Total Premium Tax Due (Line 16 plus Lines 17 and 18)
19
A COPY OF THE NEVADA PAGE FROM ANNUAL STATEMENT MUST BE ATTACHED.
NRS REQUIRES THIS RETURN MUST BE SIGNED
I hereby declare under penalty of perjury that this premium tax report (including any accompanying schedules and statements) has been examined by me and
is a true, correct and complete report.
SIGNATURE OF TAXPAYER OR AUTHORIZED AGENT
PRINTED NAME OF TAXPAYER OR AUTHORIZED AGENT
DATE
TELEPHONE #
DEPARTMENT USE ONLY
PT-01(A)
Revised 12-31-04

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