Form 20-Ins - Oregon Insurance Excise Tax Return - 2004
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4Clear Form
For office use only
OREGON
Form
Date received
•
2004
INSURANCE
20-INS
•
Payment
•
•
EXCISE TAX
Calendar Year
1
2
3
RETURN
•
•
•
(200)
Name change
Mo
/
Day
/
Year
Mo
/
Day
/
Year
If you filed a return in 2003,
SHORT YEAR ONLY
•
•
indicate if you had a:
04
04
Address change
Beginning:
Ending:
Name
Federal employer identification number (FEIN)
Oregon business identification number (BIN)
•
Mailing address
•
An extension is attached
City
State
ZIP Code
Internet address
•
Form 37 is attached
Telephone number
Contact person
•
This is an amended return
(
)
•
Complete A through D only if this is your first return or the answer
H. List the tax years for which your federal taxable income was
changed by an IRS audit or by an amended federal return filed
changed during 2004.
•
during this tax year: ____________________________________
A. Incorporated in ______________
on ______________
(state),
(date)
Send a copy of the IRS report or the amended return under
•
B. State of commercial domicile ______________________________
separate cover, if not furnished previously.
•
•
C. Date business activity began in Oregon ______________________
I. First return, indicate:
New business, or
Successor to previously existing business.
•
D. Business Activity Code from federal return ___________________
Enter name, FEIN, and BIN of previous business:
If you answer yes to E, see instructions on pa ge 2.
Name: ________________________________________________
•
E. (1) Was a consolidated federal return filed? ............
Yes
No
FEIN: ____________________ BIN: ______________________
•
(2) Is this a consolidated Oregon return? ................
Yes
No
J. Final return, indicate:
Withdrawn,
Dissolved, or
(3) Are corporations included in the consolidated
Merged or reorganized.
federal return, but not in the Oregon return? .....
Yes
No
Enter name, FEIN, and BIN of merged or reorganized corporation:
•
F. Are you a high-income taxpayer? ...........................
Yes
No
Name: ________________________________________________
•
G. List the tax years for which federal waivers of the statute of
FEIN: ____________________ BIN: ______________________
limitations are in effect and dates on which waivers expire:
•
K. If you did not complete Schedule AP, fill in the amount of your
____________________________________________________
Oregon sales: $ ________________________________________
Attach payment here
Round all amounts to the nearest whole dollar
Net income from the Annual Statement to the Insurance Commissioner:
1. Life, accident, and health companies (from page 4, line 35 of the annual statement) . ... 1
2. Less:
Income, expenses, and other items attributable to separate accounts (see page 3)
... 2
3. Subtotal (line 1 minus line 2)...........................................................................................................................3
4. Fire, property, and casualty companies
... 4
(from page 4, line 20 of the annual statement)
5. Less:
... 5
Underwriting profit derived from wet marine and transportation insurance (see page 3)
6. Subtotal (line 4 minus line 5)...........................................................................................................................6
•
7. Total (line 3 plus line 6) ...................................................................................................................................7
ADDITIONS (see instructions)
•
8. Federal income taxes deducted in arriving at line 7....................................................8
•
9. State income taxes deducted in arriving at line 7........................................................9
•
10. Penalty interest on prepayment of loans ...................................................................10
•
11. Realized gains and losses
... 11
on sales or exchanges by insurer of property excluded from line 7
•
12. Decreases in certain reserves ...................................................................................12
13. Total additions (add lines 8 through 12)........................................................................................................13
14. Income after additions (line 7 plus line 13)...................................................................................................14
SUBTRACTIONS (see instructions)
•
15. Amortization of past service credits...........................................................................15
•
16. Increases in certain reserves.....................................................................................16
•
17. Depreciation in excess of annual statement allowance.............................................17
18. Total subtractions (add lines 15 through 17).................................................................................................18
19. Income before net loss deduction (line 14 minus line 18).............................................................................19
150-102-129 (Rev. 12-04) Web
Now go to the back of this form
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