Form E-Fraternal - Annual Tax And Fees Report Foreign And Alien Life & Disability Insurer Fraternal Benefit Society - Az Department Of Insurance - 2002 Page 3
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1
2
3PART A - 2002 RETALIATORY TAX COMPUTATION
I
!
MPORTANT
E
P
S
I
,
“
”
T
R
NTER
REMIUM AMOUNTS IN BOTH COLUMNS AND IF EXEMPT FROM TAX IN THE
TATE OF
NCORPORATION
ENTER
O
IN THE
AX
ATE LINES FOR
C
A. A
A
B
P
2002 A
S
,
OLUMN
TTACH A COPY OF
RIZONA
USINESS
AGE FROM THE
NNUAL
TATEMENT
EVEN IF PREMIUMS ARE NOT TAXABLE
In the State of Incorporation Column, enter the tax computations for a like Arizona insurer doing business in your state of incorporation, using the Arizona premiums as the base
amount for taxes imposed. In the Arizona column, enter only the Arizona premiums written.
State of
Incorporation
Arizona
( A )
( B )
1.
Total Arizona Life Premiums
$
$
(FL gross/tax)
Less Deductions:
a) Paid in cash or left on deposit
(-)
b) Applied to pay renewal premiums (ONLY if included in line 1 above)
(-)
c) Other (SPECIFY)
(-)
2.
Net Taxable Life Premiums (line l minus la, lb, and lc)
$
3.
%
Life Premium Tax Rate
E
XEMPT
4.
0.00
Life Tax Due
$
$
5.
Total Arizona Annuity Considerations
$
$
(FA gross/tax)
Less Deductions (SPECIFY)
(-)
a)
b)
(-)
6.
Net Taxable Annuity Considerations (line 5 minus 5a and 5b)
$
7.
%
Annuity Consideration Tax Rate
E
XEMPT
8.
0.00
Annuity Tax Due
$
$
9.
Total Arizona Accident and Health Premiums
$
$
(FAH gross/tax)
Less Deductions (SPECIFY)
a)
(-)
b)
(-)
10.
Net Taxable Accident & Health Premiums (9 minus 9a, 9b and 9c)
$
11.
%
Accident & Health Tax Rate
E
XEMPT
12.
0.00
Accident & Health Premium Tax Due
$
$
13.
Retaliatory Worksheet Totals (Page 2, line 19)
$
$
14.
Add lines 4, 8, 12, and 13
$
$
(DOM)
15.
Total of Arizona column, line 14
$
CANNOT BE
Retaliatory Tax Due (column A, line 14 minus line 15. If result is less than “0”,
NEGATIVE
16.
enter “0”)
Carry to Page 1, Part B, line 1
←
$
(RT gross/tax)
IMPORTANT NOTE: THE RETALIATORY AMOUNT DUE MAY NOT BE OFFSET IN ANY MANNER
E-FRATERNAL (R
. 12/02)
STATE OF ARIZONA
P
3
3
EV
AGE
OF
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