Form Ib-34 - Installment Payment Property And Casualty Companies
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1
2IB-34
Installment Payment
Web
Property and Casualty Companies
1-12
North Carolina Department of Revenue
DOR Use Only
Installment Due Date
(MM-DD-YY)
Legal Name (First 35 Characters)
(USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Federal Employer ID Number
Mailing Address
NCDOR ID Number
City
State
Zip Code
Name of Contact Person
Phone Number
State of Domicile
NAIC Number
Fill in circle if applicable:
Payment has been made through electronic funds transfer (EFT)
Part 1.
Computation of Gross Premium Tax Installment
(If prior total gross premium tax liability was less than $10,000, do not
complete this form; installment payments are not required.)
,
,
,
.
1. Total Gross Premium Tax Liability
1.
00
(From prior Form IB-33, Schedule B, Part 3, Line 5)
,
,
,
.
2. Gross Premium Tax Installment Due
2.
00
Multiply Line 1 by 33 1/3% (.3333)
,
,
,
.
3. Overpayment of Gross Premium Tax to be Applied as Credit
3.
00
(From prior Form IB-33 or prior installment form)
4. Net Gross Premium Tax Installment Due
,
,
,
.
4.
$
(Line 2 minus Line 3. If less than zero, any remaining overpayment should
00
be applied to subsequent installments.)
,
,
(See for current
.
.
5. a. Penalties
b. Interest
interest rate and penalty information)
00
00
,
,
,
.
6. Total Gross Premium Tax Installment Due
$
6.
00
(Add Lines 4, 5a and 5b)
Part 2.
Computation of Insurance Regulatory Charge Installment
,
,
,
.
7. Total Insurance Regulatory Charge Liability
7.
00
(From prior Form IB-33, Schedule C, Line 4)
,
,
,
.
8. Insurance Regulatory Charge Installment Due
8.
00
Multiply Line 7 by 33 1/3% (.3333)
,
,
,
.
9. Overpayment of Insurance Regulatory Charge to be Applied as Credit
9.
00
(From prior Form IB-33 or prior installment form)
10. Net Insurance Regulatory Charge Due
,
,
,
.
(Line 8 minus Line 9. If less than zero, any remaining overpayment should
10.
00
be applied to subsequent installments.)
,
,
.
.
(See for current
11. a. Penalties
b. Interest
00
00
interest rate and penalty information)
,
,
,
.
12. Total Insurance Regulatory Charge Installment Due
$
12.
00
(Add Lines 10, 11a and 11b)
continued on Page 2
Signature:
Title:
Date:
I certify that, to the best of my knowledge, this return is accurate and complete.
Installments are due April 15th, June 15th and October 15th of each taxable year.
Your check or money order must be in the form of U.S. currency from a domestic bank.
N.C. Department of Revenue, Insurance Premium Tax Unit, P.O. Box 25000, Raleigh, NC 27640-0300
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