Form Dr-908 - Insurance Premium Taxes And Fees Return

DR-908

R. 01/15

Page 2

12. Less: Installments Paid (include quarterly statement filing fees and surcharges). See instructions.

1st Quarter ___________________________ 2nd Quarter _____________________________3rd Quarter ______________________________

US Dollars

Cents

If amended return: Add amount paid with the original return _______________________

Deduct amount refunded with the original return ( _______________ )

Total Installment Payments ...........................................................................................................................

12.

Check here

if negative

13.

13. Net Tax Due or Overpayment (Line 11 minus Line 12) .........................................................

14. Penalty (10% Late Penalty) ...........................................................................................................................

14.

15.

15. Interest (See instructions) ..............................................................................................................................

16. Amount Due With This Return. Enter on payment coupon also.

16.

(Sum of Lines 13, 14, and 15. If less than zero, enter on Line 17) ...............................................................

17.

17. Overpayment to be Refunded. Enter on payment coupon also. ................................................................

Contact person

Phone number

Fax number

E-mail address

State of domicile

Location of corporate books

All Taxpayers Are Required to Answer Questions A and B Below as Appropriate.

Is the insurer a member of an affiliated group whose parent company

Did you use the Department’s address database or third party software,

made a timely election, which included the insurer, for the alternative

where the software company indicated that they used the Department’s

salary credit calculation under section (s.) 624.509(5)(a)2, Florida

address database, when you sourced your premiums to the local taxing

Statutes (F.S.)? (Refer to Schedule IV instructions for more information.)

jurisdictions reported on Schedule XII and/or Schedule XIII? (Refer to

o YES

Schedule XII and XIII instructions for more information.)

o NO

o Department’s database

o Software company’s product where the software company

indicated that they used the Department’s address database

o NO

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct,

and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Sign here

Title

Signature of officer (must be an original signature)

Date

Preparer’s

Preparer

Preparer’s

PTIN

check if self-

Paid

signature