Form 25-104 - Texas Annual Insurance Tax Report
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225-104
b.
(Rev.2-13/20)
PRINT FORM
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Texas Annual Insurance Tax Report
A report must be filed even if no tax is due.
Surplus Lines / Purchasing Groups
under Chapters 552 and 559, Government Code, to review, request and correct
You have certain rights
71120
a. T Code
information we have on file about you. Contact us at the address or phone number listed on this form.
c. Taxpayer number
d. Filing period
e.
f. Due date
Taxpayer name and tax report mailing address (Make necessary name and address changes below)
IMPORTANT
h.
g.
Blacken this box if your mailing
address has changed. Show changes
1.
beside the preprinted information.
i.
j.
SECTION I -
Total surplus lines business as agent of record (Whole dollars only)
A. Texas premiums
A.
(reported to the Suplus Lines Stamping Office of Texas (SLSOT))
B. Texas premiums
B.
(not YET reported to the SLSOT)
C. Non-taxable premiums
C.
(reported to or subject to SLSOT reporting)
D. Other states' premiums
D.
(reported to or subject to SLSOT reporting)
Not subject to SLSOT reporting
(See instructions.)
E. Non-taxable premiums
E.
F. Other states' premiums
F.
Total Premium as Agent of Record
G. $
(Total of Items A - F)
SECTION II - Tax Base Election
(See instructions.)
1
2
Premium-written basis
Premium-received basis
SECTION III -
Surplus lines agents must complete this section using the tax base election option selected
The premiums reported in this section will not necessarily match the premiums shown in SECTION I. SECTION III premiums should reflect the premiums subject to tax on
the basis of taxation method selected, i.e., premium-received or premium-written.
1. Texas premiums
1.
(Whole dollars only) (See instructions--updated for 2011)
2. Texas returned premiums
2.
3. Taxable premiums
3.
(Item 1 minus Item 2)
4. Premium tax due
4.
(Multiply Item 3 by .0485) (Dollars and cents)
SECTION IV -
Purchasing groups and surplus lines agents writing purchasing group business must complete this section
5. Texas premiums
5.
(Whole dollars only)
6. Texas returned premiums
6.
7. Taxable premiums
7.
(Item 5 minus Item 6)
8. Premium tax due
8.
(Multiply Item 7 by .0485) (Dollars and cents)
9. Total taxes due
9.
(Item 4 plus Item 8)
10. Prepayment amount
10.
11. Total amount due
11.
(Item 9 minus Item 10)
* * * Do not detach. * * *
Form 25-104 (Rev.2-13/20)
12. Penalty and interest
12.
(See instructions.)
13. Total Amount Due and Payable
13.
(Item 11 plus Item 12)
Taxpayer name
k.
l.
T Code
Taxpayer number
Period
I declare that the information in this document and all attachments is true and correct
to the best of my knowledge and belief.
Authorized agent
Preparer's name (Please print)
Make the amount in Item 13
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
payable to:
P.O. Box 149356
Date
Daytime phone
STATE COMPTROLLER
Austin, TX 78714-9356
(Area code & number)
For information about Insurance Tax,
call 1-800-252-1387 or 512-463-4600.
111 A
Details are also available online at
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