2004 Annual Premium Tax Return
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1Form GID-12
Rev. 10/04
GEORGIA INSURANCE DEPARTMENT
PREMIUM TAX UNIT
916 WEST TOWER, #2 MARTIN LUTHER KING, JR. DRIVE
ATLANTA, GEORGIA 30334
2004 ANNUAL PREMIUM TAX RETURN
DUE MARCH 1, 2005
Report of ____________________________________________________________________________________, chartered in the state
of ______________ showing gross direct premiums received and premium tax due in the state of Georgia for the year ended December 31, 2004.
TYPE OF COMPANY: LIFE AND A&S ______ HMO ______ P&C, SURETY OR CAPTIVE ______
TITLE ______ OTHER ______
COMPANY NAIC NUMBER: ________________
ORIGINAL
AMENDED
$
Gross direct premium received on policies issued, excluding annuities.*
1.
*Attach reconciliation statement if premiums do not agree with Annual Statement. See instructions for
definition of premium.
Less premiums returned and dividends paid
2.
Taxable premiums (Line 1 minus Line 2)
3.
$
Amount of premium tax (Line 3 times .0225)
4.
ABATEMENTS AND DEDUCTIONS
$
Allowed under O.C.G.A. §33-8-5 as shown on Form GID-14
5.
Allowed under O.C.G.A. §33-8-7 as shown on Form GID-15 (Domestic P & C only)
6.
Allowed under O.C.G.A. §33-8-8 as shown on Form GID-17A (Life, A&S, and HMO only)
7.
Life and A & S guaranty assessments paid - O.C.G.A. §33-38-22 (See instructions.)
8.
County/Municipal taxes paid to Commissioner in 2004 O.C.G.A. §33-8-8.1 (Life, A&S, and HMO only)
9.
$ (
)
TOTAL ABATEMENTS AND DEDUCTIONS
10.
$
Premium tax net of abatements and deductions (Line 4 minus Line 10) (If negative, enter 0.00)
11.
$ (
)
Georgia Housing Tax Credit allowed under O.C.G.A. §33-1-18 as shown on Form IT-HC
12.
$
Retaliatory tax required by O.C.G.A. §33-3-26 as shown on Form GID-13
13.
$
Total tax liability (Line 11 Minus Line 12 Plus Line 13) (If negative, enter 0.00)
14.
PREPAYMENTS AND CREDITS
(a) Prepayment Quarter 1
$
(Do not include overpayment credit applied)
15.
(b) Prepayment Quarter 2
(Do not include overpayment credit applied)
(c) Prepayment Quarter 3
(Do not include overpayment credit applied)
(d) Prepayment Quarter 4
(Do not include overpayment credit applied)
(e) Prior Year Overpayment
(From 2003 Form GID-12, Line 17 if credit balance)
$ (
)
TOTAL PREPAYMENTS AND CREDITS (Sum of Lines 15a through 15e)
16.
$
BALANCE DUE (Line 14 minus Line 16) IF POSITIVE AMOUNT, ATTACH CHECK FOR THIS AMOUNT
17.
*** CHECK HERE IF PAYING BY EFT
Quarterly Breakdown of Premiums Collected
18.
*Required of all insurance companies regardless of tax payment method used on quarterly prepayments.
Breakdown total must equal Line 3.
Quarter 1 $
(c) Quarter 3 $
(a)
Quarter 2 $
(d) Quarter 4 $
(b)
(e) TOTAL COLLECTIONS
$
State of ________________________
County of _______________________
Before me personally appeared __________________________________________________________ who, being duly sworn, deposes and says that
Deponent Name (Please Print)
he/she is the ____________________________________________________________ of _______________________________________________________, and
Title (Please Print)
Insurance Company (Please Print)
that the foregoing information is true and correct.
Sworn and subscribed before me this _______________________________ day of ______________________________________, 20_________
Notary Public (Signature)--(Attach Seal)
Deponent (Signature)
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