Form 74a101 - Insurance Premiums Tax Return - Commonwealth Of Kentucky - 2001
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274A101 (11-01)
Commonwealth of Kentucky
Domestic Mutual, Domestic Mutual Fire
FOR OFFICIAL USE ONLY
REVENUE CABINET
or Cooperative and Assessment
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2
2 0 0 1
0 0
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2
___ ___ / ___ ___ ___ ___ / ___ ___ ___ / ___
Fire Insurance Companies
Tax
Year
Pmt. Code
Tr.
Account Number ___ ___ ___ ___ ___
FOR CALENDAR YEAR 2001
RETURN DUE MARCH 1, 2002
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 REVENUE CABINET
+
Mailing Address:
P.O. Box 1303, Frankfort, KY 40602-1303
Overnight Address:
1266 Louisville Road, Frankfort, KY 40601
The undersigned principal officer and/or chief accounting officer of the company jointly and severally certify that this return has been examined by them
and is, to the best of their knowledge and belief, a true, correct and complete return, made in good faith, for the taxable period.
_______________________________________
________________________________
_________
Signature of President or Chief Accounting Officer
Print Name
Date
REPORT PREPARER’S INFORMATION
_______________________________________
________________________________
_________
Title
Date
Signature
_______________________________________
________________________________
(
)
Print Name
Telephone Number
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