Bail Bond Companies Premium Tax - South Dakota Division Of Insurance

South Dakota Division of Insurance

445 East Capitol Avenue – Pierre, SD 57501

605-773-3563

BAIL BOND COMPANIES -- 2011 PREMIUM TAX RETURN DUE 03-01-2012

Company Name: __________________________________________________ NAIC # _______________

FEIN #: _________________ President: __________________ Domicile: ________ Group # ________

Home office address: _____________________________________________________________________

City:

___________________________________ State: ____________ Zip:_______________

Phone: _________________________________

Mailing address and contact person concerning this premium tax return:

Contact Person: ________________________________E-Mail: _____________________________

Address: ________________________________________________Direct Phone: ______________

City: ______________________________________ State: ____________ Zip: ______________

ITEMS ARE TO BE MAILED AS FOLLOWS: DUE MARCH 1, 2012

ANY POSTMARK AFTER 03-01-2012 WILL BE SUBJECT TO PENALTY FEES



1. Submit a check payable to "SD Division of Insurance" and the attached payment voucher to the following:

South Dakota Remittance Center

(ground delivery)

PO Box 5055

300 S. Sycamore Avenue, STE #102

Sioux Falls, SD 57117

Sioux Falls, SD 57110



2. Submit the Premium Tax Return, Schedule T, State Page and the Bail Bond Supplement to the following:

SD Division of Insurance

445 East Capitol Avenue

Pierre, SD 57501

Attach the Schedule T, State Page and Bail Bond Supplement to the premium tax return. Do not mail separately.



3. DO NOT SUBMIT THE PUBLICATION STATEMENT WITH THIS TAX RETURN.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

** INSTRUCTIONS **

COLUMN 1, PAGE 1: Itemize the fees that your state would charge a South Dakota domiciled company.

COLUMN 1, PAGES 2 THROUGH 4: The amounts must be those which a South Dakota Company, licensed in your state, would report to your

state using the premiums and deductions relating to South Dakota business, as shown in your current Annual Statement. All premium or income or

other taxes or fees, fines, penalties, licenses or other obligations shall be compared in aggregate (line 36) for retaliatory tax purposes. ALL

AMOUNTS MUST BE ROUNDED TO NEAREST DOLLAR.

COLUMN 1

COLUMN 2

FEES DUE MARCH 1, 2012

STATE OF INCORPORATION BASIS

SOUTH DAKOTA BASIS

1. Fee for filing annual statement

$ 25.00

2. Renewal of Certificate of Authority

$ 25.00

3. Annual Examination Assessment Fee

$ 1,000.00

4. Other (specify)

---

5. TOTAL FEES

$ 1,050.00

I declare under the penalties of perjury that this return has been examined by me and to the best of my knowledge is a true, correct and complete

return.

_________________________________________/__________________________

Signature of Officer

Title

_________________________________

____________________________________________________________________________

Date

Printed Name

Page 1.

Bail Bond Companies Premium Tax - South Dakota Division Of Insurance - 2011 Page 2

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