Installment Tax Report Form - 2005
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1INSTALLMENT TAX REPORT
DEPARTMENT OF INSURANCE
STATE OF ARIZONA
CALENDAR YEAR 2005
FINANCIAL AFFAIRS DIVISION – COMPLIANCE SECTION
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7256
Phone: (602) 912-8427 Fax: (602) 912-8421
Complete Company Name
PRINT/TYPE Preparer’s Name and Title
NAIC Number
State of Incorporation
Toll free or collect phone number
Fax number
E-Mail Address
1.
Enter the amount reported as “Total net Arizona premium taxes (2005 Installment Tax Base)” from the 2004
Annual Premium Tax and Fees Report................................................................................................................................................. $
2.
Is the amount reported on line 1 less than $2,000?
Yes – You are not required to pay Installment taxes or file this form. You may discard this form.
No – You must pay Installment taxes and file this form. Continue completing this form
THE DEPARTMENT WILL NOTIFY THE PREPARER OF THIS REPORT IF THERE IS A DISCREPANCY WITH THE INSTALLMENT BASE AMOUNT OR IF AN AUDIT OF THE
ANNUAL PREMIUM TAX REPORT RESULTS IN A CHANGE TO THE INSTALLMENT BASE AMOUNT.
3.
Enter 15% of the amount on line 1 .....................................................................................................................................................$
«
4.
The Company may decide whether to remit each Installment tax payment individually (by or before each applicable due date) or to remit a singular amount that
corresponds to two or more Installment tax payments. Please complete the following table to specify the payment(s) being made with this Report only.
PAYMENT
WRITE AN “X” IN THE BOX THAT CORRESPONDS TO THE PAYMENT(S)
ACH PAY
LINE
DUE DATE
YOU ARE REMITTING FOR THIS INSTALLMENT TAX REPORT
CODE #
4a
3/15/05
If “X”, enter the amount from line 3 here : $____________________
19
4b
4/15/05
If “X”, enter the amount from line 3 here : $____________________
20
4c
5/15/05
If “X”, enter the amount from line 3 here : $____________________
21
4d
6/15/05
If “X”, enter the amount from line 3 here : $____________________
22
4e
7/15/05
If “X”, enter the amount from line 3 here : $____________________
23
4f
8/15/05
If “X”, enter the amount from line 3 here : $____________________
24
LINE 4. TOTAL INSTALLMENT PAYMENTS (4a + 4b + 4c + 4d + 4e + 4f) FOR THIS REPORT: $
5.
A payment by check must be mailed, or an ACH payment must post to the Department’s ACH account, on or before the due date. Please use the following table to
calculate the civil penalty amount to be included in your payment [pursuant to A.R.S. § 20-225(A)] for a late Installment tax payment:
PAYMENT
ONLY ENTER INFORMATION FOR INSTALLMENT TAX PAYMENTS THAT ARE MAILED OR POSTED TO
LINE
THE DEPARTMENT’S ACH ACCOUNT AFTER THE DUE DATE(S) SHOWN IN 4a THROUGH 4f
5a
Enter larger of $25 or 5% of payment line 4a
:
$____________________
5b
Enter larger of $25 or 5% of payment line 4b
:
$____________________
5c
Enter larger of $25 or 5% of payment line 4c
:
$____________________
5d
Enter larger of $25 or 5% of payment line 4d
:
$____________________
5e
Enter larger of $25 or 5% of payment line 4e
:
$____________________
5f
Enter larger of $25 or 5% of payment line 4f
:
$____________________
LINE 5. TOTAL CIVIL PENALTIES (5a + 5b + 5c + 5d + 5e + 5f) INCLUDED FOR THIS REPORT: $
[26]
6.
A payment by check must be mailed, or an ACH payment must post to the Department’s ACH account, on or before the due date. Please use the following table to
calculate the interest amount to be included in your payment [pursuant to A.R.S. § 20-225(A)] for a late Installment tax payment:
PAYMENT
ONLY ENTER INFORMATION FOR INSTALLMENT TAX PAYMENTS THAT ARE MAILED OR POSTED TO
LINE
THE DEPARTMENT’S ACH ACCOUNT AFTER THE DUE DATE(S0 SHOWN IN 4a THROUGH 4f
6a
Line 4a amount $_________________ X 0.01 X number of full/partial months late ____: $_________________
6b
Line 4b amount $_________________ X 0.01 X number of full/partial months late ____: $_________________
6c
Line 4c amount $_________________ X 0.01 X number of full/partial months late ____: $_________________
6d
Line 4d amount $_________________ X 0.01 X number of full/partial months late ____: $_________________
6e
Line 4e amount $_________________ X 0.01 X number of full/partial months late ____: $_________________
6f
Line 4f amount $_________________ X 0.01 X number of full/partial months late ____: $__________________
LINE 6. TOTAL INTEREST (6a + 6b + 6c + 6d + 6e + 6f) INCLUDED FOR THIS REPORT: $
[26]
SUM OF TOTAL AMOUNTS ENTERED IN LINES 4, 5 AND 6 : $
7.
TOTAL PAYMENT AMOUNT
CHECK ONLY ONE BOX AND PROVIDE INFORMATION FOR THE SELECTED PAYMENT OPTION:
Check #
payable to the Arizona Department of Insurance for the amount shown on Line 7 is enclosed.
Payment in the amount shown on Line 7 will be sent via ACH delivery in the required format and content (see Form E-ACH.INSTRUCTION).
E-INSTALLMENT TAX (12/04)
P
1
1
AGE
OF
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