Form E-Healthorg - Health Organization Annual Tax And Fees Report - Department Of Insurance State Of Arizona Page 3

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COMPANY NAME_____________________________________________________ NAIC NO. ___________
PART B - ARIZONA TAXES DUE
0.00
1.
Gross Tax Amount from Part A, Page 2, line 5
$
(GT)
Less Allowable Credits:
$
a)
(EZC)
Enterprise Zone Credit from Form E-ZONE
$
b)
(MZC)
Military Reuse Zone Credit from Form M-ZONE
0.00
c) Total (line 1a plus line 1b)
$
(TAO)
0.00
d) Enter the LESSER amount of line 1 or 1c, but not less than 0
$
(TC)
0.00
2.
Adjusted Tax Amount [enter the result of line 1 minus line 1d]
$
2a.
Deduct total Health Insurance Credit Certificates received – See NOTE below
$
(HIC)
3.
Net Tax Amount (line 2 minus line 2a)
$
0.00
⇒⇒⇒⇒⇒⇒⇒⇒
Show a negative as (-)
(IB)
Installment Tax Base
4.
Enter Installment Taxes Paid (exclude penalty or interest)
a) March 15
$
b) April 15
$
c) May 15
$
d) June 15
$
e) July 15
$
f) August 15
$
0.00
g) Total of lines 4a through 4f
(-)$
(TIP)
5.
Enter the result of line 3 minus line 4g on line 5a if positive, or on 5b if negative.
0.00
a) Tax due with this report – carry to Part C, Page 1, line 1
$
(NT)
*
b) Overpayment of tax to be refunded
0.00
$
(SR)
NOTE - HEALTH INSURANCE CREDIT CERTIFICATES ISSUED BY THE ARIZONA DEPARTMENT OF REVENUE
Deduct the TOTAL amount of Health Insurance Credit Certificates issued by the Arizona Department of Revenue that are EFFECTIVE in
this Calendar Year period. The full amount of credit stated in each Credit Certificate that is effective in this Calendar Year period must be
deducted in this Calendar Year period. Do not attempt to apply Credit Certificates to multiple Calendar Year periods.
*
WARNING!
DO NOT ATTEMPT TO APPLY A TAX OVERPAYMENT TO ANNUAL FEES DUE WITH THIS REPORT. YOUR
OVERPAYMENT WILL BE REFUNDED WITHIN 90 DAYS OF THE DUE DATE OF THIS REPORT. ANNUAL FEES MUST BE PAID
WITH THIS RETURN.
CONTINUE TO PART C ON PAGE 1 FOR SUMMARY AND SIGNATURES
PENALTY FOR LATE PAYMENT OF TAX:
Late payment of tax is subject to a civil penalty equal to the greater of $25 or 5% of the tax paid late, plus interest at the
rate of 1% of the tax paid late per month from the date the tax was due.
E-HEALTHORG (R
. 12/07)
ARIZONA DEPARTMENT OF INSURANCE
P
3
3
EV
AGE
OF

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