Form Il446-0124 - Fire Marshal Tax Return - 2009
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1Illinois Department of Insurance
P.O. Box 7087
Springfield, IL 62791
State of Illinois
Calendar Year 2009 Fire Marshal Tax Return
Payable: On or before March 31, 2010 for Direct Business During the Calendar Year 2009
Web Site: (Department Links>Industry>Company Information>Tax Forms)
Federal Employer Identification Number:
By the
Insurance Company
of
Street and Number
City
State
Zip Code
For the calendar year 2009 as required by "425 ILCS 25/12" of the Illinois Compiled Statutes.
Worksheet on reverse side must be completed first
1.
Net amount of taxable premiums from Line 14 on back .................................................................. $____________________
2.
Tax due (1% of Line 1) ..................................................................................................................... $____________________
3.
Fire Marshal Tax Credit (deduct prior year overpayment; attach copy of credit letter) .................... $____________________
4.
Amount of tax paid (subtract Line 3 from Line 2) ............................................................................. $____________________
5.
Penalty for failure to file tax return ($400/month or 10% of tax, whichever is greater) .................... $____________________
6.
Penalty for failure to pay tax (10% of tax due) ................................................................................. $____________________
7.
Interest on tax paid after due date (IRS rate during tax period, 12% minimum) .............................. $____________________
8.
Total penalty and interest (add Lines 5 through 7) ........................................................................... $____________________
9.
Balance due (Line 4 plus Line 8) ..................................................................................................... $____________________
A separate check is requested for each company of an insurance group and for each tax or fee.
You must complete and return this return, even if no tax is due.
The undersigned President and Secretary of the ______________________________________________________________________
Insurance Company, being duly sworn upon their oaths say that the foregoing report and the statements contained therein and each and
every one of them are true and correct.
Date
Date
Secretary's signature
President's signature
Contact Person: ___________________________________________
Phone: (
)
Remittance should be payable to Illinois State Treasurer and mailed with the completed tax return to: Illinois Department of
Insurance, P.O. Box 7087, Springfield, Illinois 62791. File only one original copy. The official filing date is the U.S. Postal date
per 50 Ill. Adm. Code 2500.60.
Important Notice: Disclosure of this information is required under the Illinois Compiled Statutes' insurance laws. Failure to provide this
information could result in a fine. This form has been approved by the Forms Management Center.
IL446-0124 (Rev 12/09)
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Parent category: Financial