Form 802 - Virginia Insurance Premiums License Tax Surplus Lines Broker'S Annual Reconciliation Tax Report - 2014 Page 3
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3*VAF802114888*
Form 802
2014 Virginia Insurance Premiums License
Department Of Taxation
Tax Surplus Lines Broker’s Annual
PO Box 26179
Reconciliation Tax Report
Richmond, VA 23260-6179
Name of Surplus Lines Broker
Name Change
Address Change
Amended Return
Address
Account Number
(Enter FEIN Below - Required)
___ ___ ___ ___ ___ ___ ___ ___ ___
39-
F001
City, State and ZIP
Broker’s License Number
1.
Gross Premium Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.
.00
2.
Additional Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
.00
3.
Total Premium Income (Line 1 plus Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
.00
4.
Returned Premiums. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
.00
5.
Taxable Premium Amount (Line 3 minus Line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
.00
6.
Insurance Premiums License Tax (Multiply Line 5 by 2.25%) . . . . . . . . . . . . . . . . . . . .
6.
.00
7.
2014 Quarterly Taxes Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.
.00
8.
Insurance Premiums License Tax Owed.
If Line 6 is greater than Line 7, subtract Line 7 from Line 6. . . . . . . . . . . . . . . . . . . . . .
8.
.00
9.
Insurance Premiums License Tax Overpaid.
If Line 7 is greater than Line 6, subtract Line 6 from Line 7. . . . . . . . . . . . . . . . . . . . . .
9.
.00
10.
Fee for Late Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.
.00
11.
Penalty for Late Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.
.00
12.
Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12.
.00
13.
Total Adjustments. Add Lines 10, 11 and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13.
.00
14.
If you owe tax on Line 8, add Line 8 and Line 13. If you have an overpayment on Line
9, but Line 13 is greater than Line 9, subtract Line 9 from Line 13. This is the total
payment due. Enter the sum here and on the voucher below . . . . . . . . . . . . . . . . . . . .
14.
.00
15.
If you have an overpayment on Line 9 and Line 9 is greater than Line 13, subtract
Line 13 from Line 9. This is your refund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15.
.00
Under penalty of perjury, I declare that I have examined this report and to the best of my knowledge and belief, it is true, correct and complete.
Surplus Lines Broker/Agency Office Signature
Date
Day Time Phone Number
Preparer’s Name, Firm Name
Vendor Code
Preparer’s Phone Number
Form 802V
Virginia Insurance Premiums License Tax
You must file this voucher with
Form 802, unless reporting and
(Doc ID 802)
Surplus Lines Broker’s
paying electronically.
Annual Reconciliation Tax Report Voucher
0000000000000000 8028888 000000
2014
Taxable Year
Account Number (Enter FEIN Below - Required)
Broker License Number
Required:
39-
___ ___ ___ ___ ___ ___ ___ ___ ___
F-001
Send the signed return (above) and this
Name of Surplus Lines Broker
voucher, even if no tax is due.
Total Amount Due
Address
(Line 14 of the above return.)
City, State and ZIP
00
.
Va. Dept. of Taxation 802 Web 2616019 REV 06/14
Page 3
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