Quarterly Industrial Insurance Premium Tax Return - Nevada Department Of Taxation

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Taxpayer ID #
_ _____________________
Federal ID #
_______________________
Nevada Department of Taxation
1550 College Parkway, Rm. 115
Department Use Only
Carson City, NV 89706
Phone: (775) 684-2000
Amount
Fax: (775) 684-2020
Check No.
QUARTERLY INDUSTRIAL INSURANCE PREMIUM TAX RETURN
Date Rec'd
Initials
Period Ending
Due Date
- Industrial Insurance Only
Net Quarterly Taxable Premiums/Considerations
1. Amount of taxable net direct Industrial Insurance premiums written and net considerations
received this quarter
2. Gross premium tax (3.5% or .035 of Line 1)
3. Industrial Insurance credit (NRS 680B.036)
(
)
4. Net premium tax (Line 2 minus Line 3)
5a. Home office credit, if qualified (NRS 680B.050) (50% or .5 of Line 4)
If Line 4 is Zero or less than Zero, enter Zero on Line 5
5b. Amount of Ad Valorem Taxes Paid, if qualified for Home Office
Credit (NRS 680B.050)
5c. Max credit allowed. (See instructions)
5d. Available Home Office and Ad Valorem Taxes credit. Enter the lessor of Lines 5a plus 5b or 5c.
6. Property/Casualty Guaranty Association Credit (NRS 687A).
7. Net Premium Tax (Lines 4 minus 5d minus line 6).
8. Penalty (See Instructions for Rate).
9. Daily Interest. Net Premium Tax due (Line 7) multiply by .00049315068 times the number of days late.
10. Total Amount Due (Lines 7 plus Lines 8 through 9).
NRS REQUIRES THAT THIS RETURN MUST BE SIGNED
I hereby declare under penalty of perjury that this premium tax return has been examined by me and is a true, correct and complete report.
Signature of Taxpayer or Authorized Agent
Printed name of Taxpayer or Authorized Agent
Date
Telephone
Insurance
IIP
10-08-07

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