Form 74a100 - Insurance Premiums Tax Return - 2002
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474A100 (12-02)
Commonwealth of Kentucky
INSURANCE PREMIUMS
FOR OFFICIAL USE ONLY
REVENUE CABINET
TAX RETURN
3 2
2 0 0 2
*
___ ___ / ___ ___ ___ ___ / ___
Tax
Year
Tr.
For Calendar Year 2002
Account Number ___ ___ ___ ___ ___
Return Due March 3, 2003
NAIC/
FEIN __ __ – __ __ __ __ __ __ __
TAX ID
Company Name
Home Office Address (Number and Street)
Mailing Address (Post Office Box)
Telephone Number
City
State
ZIP Code
SUMMARY OF NET TAX DUE (All Sections)
.
$
A.
Net domestic and foreign life insurance tax (from Section I, line J) ................................. (01)
.
B.
Net other than life insurance tax (from Section II, line M) ............................................... (02)
.
C.
Fire insurance tax (from Section III, line E) ...................................................................... (05)
.
D.
Net retaliatory taxes and fees (from section IV, Part C, line 9) ......................................... (06)
$_____________________________
E.
Total net tax liability due (add lines, A, B, C and D). Pay in full with this return ...............
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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