Form 74a101 - Insurance Premiums Tax Return
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1
274A101 (4-11)
Domestic Mutual, Domestic Mutual Fire
FOR OFFICIAL USE ONLY
Commonwealth of Kentucky
or Cooperative and Assessment
DEPARTMENT OF REVENUE
Fire Insurance Companies
3
2
2 0
0 0 1 2
___ ___ / ___ ___ ___ ___ / ___ ___ ___/___
Tax
Year
Pmt. Code
Tr.
FOR CALENDAR YEAR 20___
Account Number ___ ___ ___ ___ ___
INSURANCE PREMIUMS TAX RETURN
NAIC/
FEIN __ __ – __ __ __ __ __ __ __
TAX ID
Company Name
Home Office Address (Number and Street)
Mailing Address (Post Office Box)
Telephone Number
City
State
ZIP Code
SECTION I—REPORT OF PREMIUMS PAID TO UNAUTHORIZED REINSURANCE COMPANIES
Name of Unauthorized
Amounts of
Address
Reinsurance Company
Premiums Paid
$
Total Premiums Paid to Unauthorized Reinsurance Companies ................................................... $
Tax Liability—2% of Total Unauthorized Premiums .................................................................... $
.
➤
Make check payable to Kentucky State Treasurer and mail return with payment to:
KENTUCKY DEPARTMENT OF REVENUE
+
Mailing Address:
P.O. Box 1303, Frankfort, KY 40602-1303
Overnight Address:
501 High Street, Frankfort, KY 40601-2103
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.
______________________________________________
__________________________________
_____________________
Signature of President or Chief Accounting Officer
Print Name
Date
REPORT PREPARER’S INFORMATION
______________________________________________
__________________________________
_____________________
Signature
Title
Date
(
)
______________________________________________
__________________________________
Print Name
Telephone Number
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