Schedule 800ret Cr - Virginia Application For Retaliatory Costs Tax Credit - 2014
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1Application for Retaliatory
Schedule 800RET CR
For Calendar Year
Costs Tax Credit
2014
Company Name
Federal Employer ID Number
Address
NAIC/License #
City, State and ZIP Code
State of Domicile
1.
Retaliatory Cost paid, as defined in Va. Code § 58.1-2510. . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.
.00
2.
If the Retaliatory Costs Tax Credit was received for taxable year 2000, enter the amount
from Line 1 multiplied by 100%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
.00
3.
If the Retaliatory Costs Tax Credit was not received for taxable year 2000, enter the
amount from Line 1 multiplied by 60%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
.00
4.
Retaliatory Costs Tax Credit carryover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
.00
5.
Total Retaliatory Costs Tax Credit available (Add Lines 2, 3 and 4). . . . . . . . . . . . . . . . . . . . . .
5.
.00
6.
Check the applicable box to identify your refund.
The amount on Line 2 is greater than 0. Your refund cannot exceed $7,000,000. Provide
details on the schedule below to allocate the credit amount available on Line 5. Attach a
separate schedule if more space is needed.
The amount on Line 3 is greater than 0. Your refund cannot exceed $800,000. Provide
details on the schedule below to allocate the credit amount available on Line 5. Attach a
separate schedule if more space is needed.
Name
FEIN
NAIC
Amount
.00
.00
.00
.00
.00
.00
7.
Total Refundable Retaliatory Costs Tax Credit allocated. Enter the total from Line 6 . . . . . . . .
7.
.00
8.
Enter Refundable Retaliatory Costs Tax Credit amount allocated above and claimed on this
return. Enter here and on Schedule 800CR, Line 42 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.
9.
Carryover Retaliatory Tax Credit. Subtract Line 7 from Line 5. This is the amount of
Retaliatory Tax Credit to be carried forward to taxable year 2015. . . . . . . . . . . . . . . . . . . . . . .
9.
.00
I certify that the above information is true and correct to the best of my knowledge.
Signature
Phone Number
Title
Date
Certified Public Accountant Statement:
I certify that the above named insurance company (or group) is a “qualified company” as defined by Va. Code § 58.1-2510 B and is
eligible to apply for the credit for Retaliatory Costs paid to other states by:
Having an increase, as of December 31, 1997, of at least 325 qualified full-time employees above the company’s employment
level in Virginia on December 31, 1996;
OR
Having more than 100 qualified full-time employees in Virginia during the entire taxable year, beginning on or after January 1,
2001.
Signature of Authorized Representative
Phone Number
Firm Name and Address
Date
800RETCR 2616024 Rev 05/14
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