Form 1366 - Insurance Company Annual Return For Sbt And Retaliatory Tax - 2004 Page 2
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1
2Foreign and alien insurers complete lines 31 - 47. Domestic insurers go to line 47.
31.
Enter the amount from line 30
31.
Column A
Column B
State of Incorporation
Michigan
TAXES
32.
State of incorporation tax
32.
33.
Michigan single business tax from line 31
33.
FEES AND ASSESSMENTS
25.00
34.
Annual statement filing fee
34.
35.
Certificate of Authority renewal fee
35.
36.
Certificate of Compliance
36.
37.
Certificate of Deposit
37.
38.
Certificate of Valuation
38.
39.
Enter the total of other fees paid in the state of
incorporation. Attach a detailed schedule of fees
39.
40.
Fire Marshall Tax
40.
41.
Second Injury Fund
41.
42.
Silicosis & Dust Disease Fund
42.
43.
Safety Education and Training Fund
43.
44.
Enter the total of all other assessments. Attach
a detailed schedule of assessments
44.
TOTAL
4
4
45.
Total taxes and assessments. Add lines 32 - 44
45.
4
46.
46.
Retaliatory amount. Subtract line 45 column B from column A; not less than 0
4
47.
47.
Amount due. Add lines 31 and 46. Domestic insurers enter the amount from line 30
PAYMENTS, REFUNDABLE CREDITS AND TAX DUE
48.
Credit forward from 12/31/2003 SBT return, line 60
48.
49.
Estimated tax payments
49.
50.
Tax paid with request for extension
50.
51.
Refundable Credits from C-8000MC, line 14
51.
4
52.
52.
Total Payments. Add lines 48 through 51
a.
Add to line 52 any payment of tax made with the original return
Complete this line
OR
53.
only if amending a
b.
Subtract from line 52 any refund of tax received with the original return
return.
4
c.
Net payments
53.
Amended filers use line 53 instead of line 52 for all references below.
4
54.
54.
TAX DUE. Subtract line 52 from line 47. If less than zero, leave blank
55.
55.
Underpaid estimate penalty and interest. See instructions
56.
56.
Annual return penalty at
% =
.00 and interest at
% =
.00
57.
PAYMENT DUE. Add lines 54 - 56. Enter this amount here and on page 1, line 61
57.
OVERPAYMENT - REFUND OR CREDIT FORWARD
58.
OVERPAYMENT. If line 52 is more than line 47, subtract line 47 from line 52
58.
4
59.
Enter the amount of overpayment on line 58 to be refunded
59.
4
60.
Enter the amount of overpayment on line 58 to be credited forward
60.
This return must be filed by March 1, 2005.
SIGNATURE AND PREPARER AUTHORIZATION
TAXPAYER'S DECLARATION
PREPARER'S DECLARATION
I declare under penalty of perjury that this return is based on all information of
I declare under penalty of perjury that this return is true and correct to the best of my
which I have any knowledge.
knowledge.
Perparer's Signature
Date
I authorize Treasury to discuss my return with my preparer.
Yes
No
Taxpayer's Signature
Date
Business Address and Telephone
Title
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