Form 74a110 - Kentucky Estimated Insurance Premiums Tax - 2012
ADVERTISEMENT
1
2
374A110 (1-12)
KENTUCKY ESTIMATED
FOR OFFICIAL USE ONLY
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
INSURANCE PREMIUMS TAX
3
2
0 6 1 2
*
___ ___ / ___ ___ ___ ___ / ___
Tax
Year
Tr.
For Calendar Year 2012
Account Number ___ ___ ___ ___ ___
Due June 1, 2012
NAIC/
FEIN __ __ – __ __ __ __ __ __ __
TAX ID
FIRST INSTALLMENT
Check appropriate block:
Name of Company
Report based on previous year’s liability
Address
Number and Street
Report based on current year estimate
City, Town or Post Office
State
ZIP Code
.
(01)
A. Premiums tax on life and health policies ...................................................
$
B. Premiums tax on other than life policies (excluding
.
workers’ compensation policies) ............................................................... (02)
.
C. Retaliatory taxes and fees on foreign and alien insurers ...........................
(06)
.
D. Total installment due (total of lines A, B and C) .......................................
$
I, the undersigned, declare under the penalties of perjury, that I have examined these returns, including all accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.
____________________
___________________________________________
______________________
Date
Signature of Officer or Agent
Title of Officer
___________________________________________
______________________
Telephone Number
Print or Type Name of Officer or Agent
DETACH BEFORE MAILING
74A110 (1-12)
KENTUCKY ESTIMATED
FOR OFFICIAL USE ONLY
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
INSURANCE PREMIUMS TAX
3
2
1 0 1 2
*
___ ___ / ___ ___ ___ ___ / ___
Tax
Year
Tr.
For Calendar Year 2012
Account Number ___ ___ ___ ___ ___
Due October 1, 2012
NAIC/
FEIN __ __ – __ __ __ __ __ __ __
TAX ID
SECOND INSTALLMENT
Check appropriate block:
Name of Company
Report based on previous year’s liability
Address
Number and Street
Report based on current year estimate
City, Town or Post Office
State
ZIP Code
.
A. Premiums tax on life and health policies ...................................................
(01)
$
B. Premiums tax on other than life policies (excluding
.
workers’ compensation policies) ............................................................... (02)
.
C. Retaliatory taxes and fees on foreign and alien insurers ...........................
(06)
.
D. Total installment due (total of lines A, B and C) .......................................
$
I, the undersigned, declare under the penalties of perjury, that I have examined these returns, including all accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.
____________________
___________________________________________
______________________
Date
Signature of Officer or Agent
Title of Officer
___________________________________________
______________________
Telephone Number
Print or Type Name of Officer or Agent
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial