Form Mo 375-0429 - Chapter 380 Missouri Mutual Companies - 2011 Page 2

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company name

naic no.

report all missouri direct premiums or assessments received, whether in cash or in notes, during the year ending on the 31st day

of december. include all so-called premium deposits, membership fees, service and finance charges. missouri does tax commis-

sion retained by agents. this must be included with your direct premiums written.

1. total direct premiums or assessments to agree with missouri premiums/assessment page

of your annual statement (column 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

a. plus finance, service or other carrying charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

b. less dividends paid or credited or refunds (column 3) . . . . . . . . . . . . . . . . . . . . . . . . $____________

c. less federally reinsured multiple peril crop insurance . . . . . . . . . . . . . . . . . . . . . . . . $____________

d. less first $1,000,000 exempted premiums/assessments . . . . . . . . . . . . . . . . . . . . . . . $____________

Net Premiums/Assessments Subject to Taxation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

2. amount of premiums/assessments written between $1,000,000 and $5,000,000 . . . . . . . $____________

3. Tax at 1% of Line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ____________

4. amount of premiums/assessments written in excess of $5,000,000 . . . . . . . . . . . . . . . . . $____________

5. Tax at 2% of Line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ____________

6. Missouri Premium Tax (Line 3 plus Line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

7. Credits Allowed

total credit available

amount deducted

for current year

on this return

income tax (148.400 rsmo) . . . . . . . . . . . . . . . . . . . . . . . . . .

$____________

franchise tax (148.400 rsmo) . . . . . . . . . . . . . . . . . . . . . . . .

$____________

2011 examination fees (148.400 rsmo) . . . . . . . . . . . . . . . .

$____________

examination fee carryover 2006-2010 (148.400 rsmo) . . . . . . . .

$____________

registration fees - paid in 2011 (148.400 rsmo) . . . . . . . . .

$____________

personal property tax - paid in 2011 (148.400 rsmo) . . . . .

$____________

missouri p & c ins. guaranty assn. (375.774 rsmo) . . . . . . . . .

$____________

affordable housing (32.111 rsmo) . . . . . . . . . . . . . . . . . . . . .

$____________

neighborhood development (32.105 rsmo) . . . . . . . . . . . . .

$____________

neighborhood assistance (32.115 rsmo) . . . . . . . . . . . . . . . .

$____________

infrastructure development (100.286 rsmo) . . . . . . . . . . . . .

$____________

enterprise Zone/urban redevelopment (135.200 rsmo) . . .

$____________

low income housing (135.352 rsmo) . . . . . . . . . . . . . . . . . .

$____________

small business investment (135.403 rsmo) . . . . . . . . . . . . .

$____________

youth opportunities (135.460 rsmo) . . . . . . . . . . . . . . . . . . .

$____________

capco investment (135.500 rsmo) . . . . . . . . . . . . . . . . . . .

$____________

neighborhood preservation (135.535 rsmo) . . . . . . . . . . . . .

$____________

domestic Violence shelters (135.550 rsmo) . . . . . . . . . . . . .

$____________

maternity home facilities (135.600 rsmo) . . . . . . . . . . . . . . .

$____________

historic structure rehabilitation (253.557 rsmo) . . . . . . . . . .

$____________

agricultural utilization (348.430 rsmo) . . . . . . . . . . . . . . . . . .

$____________

new generation cooperative incentive (348.432 rsmo) . . . . . . . .

$____________

new enterprise creation (620.650 rsmo) . . . . . . . . . . . . . . .

________

____

____________

other __________________________________ . . . . . . . . . . . $____________

$____________

other __________________________________ . . . . . . . . . . . $____________

$____________

8. Net Missouri Tax (Round to nearest whole dollar) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

mo 375-0429 (10-11)

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