Form Cdi Fs-004 - Home Protection Tax Return - California Department Of Insurance - 2011
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1
2State of California
Department of Insurance
HOME PROTECTION TAX RETURN
CDI FS-004 (REV 9/2011)
2011
FOR CALENDAR YEAR
TAX DUE DATE APRIL 1, 2012
Name of Insurer
Fed Tax I.D. No.
CA Perm No.
NAIC No.
Mailing Address
EFT Taxpayer I.D. No.
City, State, Zip
Method of
No Payment
Tax Payment
Telephone & Fax #
Check
State of Domicile
EFT
If New Company, check here
If Name Change, check here
If Final Return, check here
If Amended Return, check here
and indicate the effective date of the final transaction.
and indicate the date when it was amended
STATEMENT OF DIRECT CONTRACT FEES DURING CALENDAR YEAR 2011
CDI use only
1.
Direct Premiums Written (Sch. T, Line 5, Column 3)
1.
2.
Additional Contract Fees directly paid by Contract-holder
2.
3. Orphan Premiums
3.
4. Total Net Taxable Premiums
4.
2.35%
5.
Tax Rate
5.
6.
2011 Annual Tax
6.
7
Low Income Housing Credit
7.
8.
CA CDFI Credit (COIN)
8.
9.
Prepayments Made During the Reporting Year of 2011
a.
Overpayment applied from prior yr.
b.
First Quarter (Balance paid)
c.
Second Quarter
d.
Third Quarter
e.
Fourth Quarter
f.
Total Prepayments
9f.
10
Total Credits & Prepayments Made
10.
11.
2011 Tax Due - If Line 6 is greater than Line 10
11.
12.
2011 Tax Overpayment - If Line 10 is greater than Line 6
12.
The tax overpayment (line 12) may be applied to the 2012
first quarter prepayment (line 13).
A Refund SHALL NOT be applied to the 2012 second
quarter prepayment or any future tax payment.
13.
2012 First Quarter Prepayment
13.
a.
2011 Tax Overpayment applied to the 1st Quarter Prepayment
a.
b.
2012 First Quarter Prepayment Balance Due
13b.
14.
Tax Refund
14.
Line 11
2011Tax Due
Line13b.
2012 First Quarter Prepayment Balance Due
Each Payment must be paid separately and should NOT be
combined to make one lump sum payment
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