Form E-Tax - Annual Tax And Fees Report Page 2
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9INSURANCE TAX UNIT
ANNUAL TAX AND FEES REPORT
Arizona Department of Insurance
FORM E‐TAX | SCHEDULE I
th
2910 North 44
Street, Suite 210
Phoenix, AZ 85018‐7269
(Installment Payments)
2012
____
Phone: (602) 364‐3997 | Fax (602) 364‐3989
for the calendar year ended December 31,
Name of Insurer
NAIC #
Domicile
Business Type Code
Entity Type Code
Complete the ‘Amended Report‘ and ‘Difference’ columns only if you are filing an amended report.
Only report the installment portion of payments you made. Exclude any penalty and interest that you included as part of your
payments.
If you made more than one payment for a single installment period, enter the sum of the installment amounts you paid for the
installment period (again excluding penalty and interest).
Difference
Installment Period
Original Report
Amended Report
(Amended – Original)
2012
A. Installment amount paid for installment due 3/15/ ______
2012
B. Installment amount paid for installment due 4/15/ ______
2012
C. Installment amount paid for installment due 5/15/ ______
2012
D. Installment amount paid for installment due 6/15/ ______
2012
E. Installment amount paid for installment due 7/15/ ______
2012
F. Installment amount paid for installment due 8/15/ ______
2012
G. TOTAL INSTALLMENT AMOUNTS PAID IN ______ (Sum of
0.00
0.00
0.00
Line A through Line F). Enter on Form E‐TAX, Line M.
H. EXPLANATIONS. Provide any explanation you believe is needed concerning amounts entered on this schedule.
ADOI — 03/08/13
11:21 am
Annual Tax and Fees Report: SCHEDULE I
Form E‐TAX (v. 20130307)
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