Form 4904 To 4905 - Michigan Corporate Income Tax For Insurance Companies

4905, Page 2

Taxpayer FEIN

Foreign and alien insurers complete lines 26 through 40. Domestic insurers, skip to line 41.

State of Incorporation

Michigan

TAXES

X X X X X X X X

26. State of incorporation tax.......................................................................

26.

X X X X X X X X

27. Michigan Tax from line 25 ......................................................................

27.

FEES AND ASSESSMENTS

28. Annual statement filing fee ....................................................................

28.

X X X X X X X X

29. Certificate of Authority renewal fee ........................................................

29.

30. Certificate of Compliance ......................................................................

X X X X X X X X

30.

31. Certificate of Deposit .............................................................................

X X X X X X X X

31.

32. Certificate of Valuation ...........................................................................

X X X X X X X X

32.

33. Enter total of other fees paid in the state of incorporation.

Attach a detailed schedule of fees.........................................................

33.

X X X X X X X X

34. Fire Marshall Tax ...................................................................................

34.

35. Second Injury Fund ...............................................................................

35.

36. Silicosis and Dust Disease Fund ...........................................................

36.

37. Safety Education and Training Fund .....................................................

37.

38. Enter total of all other assessments.

Attach a detailed schedule of assessments ..........................................

38.

TOTAL

39. Total Taxes, Fees and Assessments. Add lines 26 through 38 .............

39.

40. Retaliatory Amount. Subtract line 39, column B, from column A. If less than zero, enter zero.............................. 40.

41. Total Tax Liability. Add lines 25 and 40. Domestic insurers, enter amount from line 25....................................... 41.

PAYMENTS AND TAX DUE

42. Overpayment credited from prior return ................................................................................................................. 42.

43. Estimated tax payments ......................................................................................................................................... 43.

44. Flow-Through Withholding payments ....................................................................................................................

44.

45. Tax paid with request for extension ........................................................................................................................ 45.

46. Workers’ Disability Supplemental Benefit (WDSB) Credit (attach document) ........................................................ 46.

47. Total Payments. Add lines 42, 43, 44, 45 and 46 ................................................................................................... 47.

48. TAX DUE. Subtract line 47 from line 41. If less than zero, leave blank .................................................................. 48.

49. Underpaid estimate penalty and interest from Form 4899, line 38. ........................................................................ 49.

50. Annual Return Penalty (see instructions) ............................................................................................................... 50.

51. Annual Return Interest (see instructions) ............................................................................................................... 51.

52. PAYMENT DUE. If line 48 is blank, go to line 53. Otherwise add lines 48, 49, 50 and 51 ..................................... 52.

OVERPAYMENT, REFUND OR CREDIT FORWARD

53. Overpayment. Subtract line 41, 49, 50 and 51 from line 47. If less than zero, leave blank (see instructions) ........... 53.

54. CREDIT FORWARD. Amount on line 53 to be credited forward and used as an estimate for next tax year ............. 54.

55. REFUND. Subtract line 54 from line 53 .................................................................................................................. 55.

Taxpayer Certification.

Preparer Certification.

I declare under penalty of perjury that the information in

I declare under penalty of perjury that this

this return and attachments is true and complete to the best of my knowledge.

return is based on all information of which I have any knowledge.

Preparer’s PTIN, FEIN or SSN

By checking this box, I authorize Treasury to discuss my return with my preparer.

Authorized Signature for Tax Matters

Preparer’s Business Name (print or type)

Authorized Signer’s Name (print or type)

Date