Form 83-391-12-8-1-000 - Mississippi Insurance Company Income Tax Return

Form 83-391-12-8-1-000 - Mississippi Insurance Company Income Tax Return - 2012 Page 4

Mississippi

Form 83-391-12-8-4-000 (Rev. 05/12)

Insurance Company Income Tax Return

2012

Page 4

FEIN

__ __

__ __ __ __ __ __ __

PART I: DEDUCTIONS APPORTIONED

(From Annual Statement)

Expenses must be separately apportioned. Attach supplementary pages to return as needed.

Column (

)

Page

Line

Description

B. Less Allocable

Balance

Expenses

Apportionable

1. Totals

(Total Column A Minus Total Column B)

2. Applicable Expense Apportionment Ratio

(From Page 3, Part I)

__ __ __ . __ __ __ __

3. Total Apportioned to Mississippi

(Multiply Line 1, Column C By Line 2, Column C. Enter Result Here and on Page 3, Part III, Line 21)

PART II: RETALIATORY TAXES PAID

(Mississippi Corporations Only)

Itemize retaliatory taxes paid by state and attach copies of returns documenting amounts. Attach supplementary schedules as needed.

Taxing Authority

Amount

1. Total Amounts

(Total Amounts from Column B. Enter Here

and on Page 1, Line 3.)

Form 83-391-12-8-1-000 - Mississippi Insurance Company Income Tax Return - 2012 Page 4