Schedule 844 - Virginia Statement Of Exemption Mutual Assessment Property & Casualty Insurers

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Schedule 844
Statement of Exemption
*VAS844113888*
Mutual Assessment
Property & Casualty Insurers
Company Name
Federal Employer ID Number
NAIC/License #
I certify that the company named above is exempt from paying the Insurance Premiums License Tax on
direct premium income as prescribed in Va. Code § 58.1-2502. This company operates in the counties
and/or cities shown below (please indicate the corresponding population):
Counties/Cities
Population
I certify that the above information is true and correct to the best of my knowledge.
Signature of Officer
Printed Name
Title
Date
Preparer’s Name
Preparer’s Phone Number
Sch 844 6201180 Rev 05/13

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