Form E-Hcso - Annual Net Charges Tax And Fees Report - 2000
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3ARIZONA DEPARTMENT OF INSURANCE
2000 ANNUAL NET CHARGES TAX AND FEES REPORT
Foreign Due Date: March 1, 2001
HEALTH CARE SERVICES ORGANIZATIONS
Arizona Domestic Due Date: March 31, 2001
PREMIUM TAX UNIT
(602) 912-8429
FAX (602) 912-8421
For Office Use Only
For Audit Use Only
! ! ! ! !!! !!! !!! !!!! ! ! ! ORIGINAL REPORT
! ! ! ! !!! !!! !!! !!!! ! ! ! AMENDED REPORT / REASON ____________________________________________________________________________________
Complete Company Name and Home Office Address
State of Incorporation
x
X
x
NAIC Number
x
NAIC Group Number
x
Federal I. D. Number
x
Preparer’s Name and Title:
Toll Free or Collect Phone: (
)
FAX: (
)
Complete Mail Address:
PART C – SUMMARY OF TAXES AND FEES DUE
1)
Arizona Net Charges Tax (Part B, Page 3, line 4a – not less than zero)
$
(Pay Code 07)
2)
Certificate of Authority Renewal Fee
$
62.50
(Pay Code 63)
250.00
3)
Annual Statement Filing Fee
$
(Pay Code 28)
$
4)
TOTAL DUE – NOT LESS THAN $312.50 (See above due dates)
(Add lines 1 through 3, above – DO NOT ROUND TO NEAREST DOLLAR )
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AKE CHECK PAYABLE TO AND
Attention: TAX UNIT
:
MAIL CHECK WITH REPORT TO
2910 North 44
Street, Second Floor
th
Phoenix, Arizona 85018-7256
PREPARER CERTIFICATION
COMPANY OFFICER CERTIFICATION
I certify that I have prepared this report. It is true, complete and correct to the best
I certify that I have examined this report. It is true, complete and correct to the best
of my knowledge.
of my knowledge.
SIGNATURE OF PREPARER
DATE
SIGNATURE OF OFFICER
DATE
NAME AND TITLE TYPED OR PRINTED
NAME AND TITLE TYPED OR PRINTED
E-HCSO (12/00)
PAGE 1 of 3
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