Federal Income Tax Extension Form

Document Sample
Federal Income Tax Extension Form Powered By Docstoc
					                                     Department of Consumer and Business Services
                                                 Insurance Division — 4
                                         P.O. Box 14480, Salem, OR 97309-0405
                                                   Phone: 503-947-7046
                                    350 Winter St. NE, 3rd floor, Salem, OR 97301-3883
                                                      insurance.oregon.gov
                                                                                                        Amended Insurance
                                                                                                           Tax Return
Instructions
Filing Due Dates           Insurance Tax Return                           April 1
                           Renewal of Certificate of Authority            April 1
                           Recoupment of OIGA Assessments                 June 1
                           Ocean Marine Tax Report                        June 15
Postmarks will be accepted as the filing date. Any unpaid tax as of the due date of the original return will be subject to a
penalty of 10 percent of the unpaid tax and will also incur interest from the original due date. Interest is charged at the rate of
.667 percent of the unpaid tax for each month, or fraction of a month. Make all checks payable to the Department of Consumer
and Business Services.
Address Corrections – Mark the box for a name or address change. Be sure to list the contact person, his or her phone
number, and e-mail address. The address listed on the tax form is the address where all Oregon insurance tax information will
be sent, including the assessment coupon and the prepayment coupons.
Oregon Insurance Excise Tax – If you need excise tax return forms, contact the Department of Revenue at 503-378-4988.
The Oregon Department of Revenue Excise Tax Return (Form 20-INS or Form 20) is due April 15. However, in order to
complete the Insurance Division tax forms, your company must first prepare its Oregon Insurance Excise Tax on Form 20-INS
(Form 20 for title insurers). The excise amount from that form is necessary in order to complete the Oregon Insurance Division
tax forms.
NOTE: Companies may use an estimated corporation excise tax amount on their Oregon Insurance Division tax forms due
April 1 if a final excise tax return has not been filed or the return is under extension with the Oregon Department of Revenue.
If the excise tax is estimated, check the estimated box on Part II, Retaliatory Tax.
If an estimated excise tax amount is used, companies will need to file amended Insurance Division tax forms when the
final excise tax figures are available. Interest will be charged for underpayment of Fire Marshal or retaliatory tax. In some
cases, the Insurance Division will send you a bill (refund) when the final amounts are known.
Filling out the Amended Insurance Division Tax Forms
                                                      Complete the following schedules in this order:
For P and C Companies:                                Schedule A – Report of Premiums
                                                      Schedule B – Workers’ Compensation Premium Fund Assessment
                                                      Schedule C – Agent appointments
                                                      Part I – State Fire Marshal Tax
                                                      Part II – Retaliatory Tax (Domestic P and Cs do not have to fill out Part II)
                                                      Summary of Taxes Due (Page 1 of Insurance Tax Return.)
For L and H and HCSC Companies:                       Schedule A – Report of Premiums
                                                      Schedule C – Agent appointments
                                                      Part II – Retaliatory Tax (Domestic companies do not have to fill out Part II)
                                                      Summary of Taxes Due (Page 1 of Insurance Tax Return.)


Note for Page 1 – Page 1 of the Insurance Tax Return has an affidavit that is to be signed by two employees, one of whom
must be a corporate officer. The affidavit must also be notarized.

440-4760 (10/09/COM/WEB)                                                                                                Tax instructions
Note for Part II – Retaliatory Tax – Do not include any Guaranty Association Assessments in the calculation of the home
state basis or the Oregon basis. If your domicile state charges Oregon insurers any of the following assessments, you must
include them in the Home (Domicile) State Basis:
     Agents’ appointment fees and termination fees
     Fraud fee assessments                                                                            What would an
     Insurance Department regulation fee or administrative assessment                                 Oregon insurer
     Auto assessments (even if recouped from policyholders)                                           have to pay in my
     Health Insurance Pool assessments (similar to Oregon Medical Insurance Pool)                     state? Use those
                                                                                                      fees on the Home
     Workers’ Compensation Fund assessments or administrative funds
                                                                                                      (or Domicile)
     Second Injury Fund assessments                                                                   State Basis.
     State corporate income or excise taxes or franchise taxes
     Fire Marshal taxes or assessments
     Fire Fighters Training Funds or Retirement Funds assessments
     Most fees or assessments imposed but not listed above

If a fee is a minimum or flat fee, enter it on the Home State Basis. Other fees will need to be calculated on an Oregon
basis (using Oregon premiums, number of agents appointed in Oregon, etc.). Please list these fees and the amounts
separately on Part II, Retaliatory Tax. Show how you calculated these fees on an Oregon basis. Please call if you have
questions whether a fee should be included in the Home (Domicile) State Basis.

Notes for Schedule A – Report of Premium by Insurer – Schedule A must be completed by all insurers and is used for
Insurance Division purposes only. The amounts listed are not used on any other part of the tax return. Title companies should
use Schedule A, Line 1 to report the sum of the amounts in columns 3, 4, and 5 on Line 38 of Schedule T of the Annual
Statement.


Notes for Schedule C – Agent Appointments – Complete Schedule C only if your domicile state charges agent appointment
fees. Please enter zero if you have no agents doing business in Oregon. The number of agents should be used to calculate Line
3 of Part II - Retaliatory Tax. You can include a worksheet showing the calculation of the agent appointment fees.
QUESTIONS?
Can I use forms generated by a software program? The Insurance Division will accept forms generated from computer
software programs only if forms are exactly like the original in content and appearance (including Oregon certificate of
authority number and company address). All tax forms may be submitted on single-sided or double-sided paper. Please
use only 8½-inch by 11-inch paper.

What if our state excise tax return is on extension? If your state excise tax is on extension, you may use an estimated
number on the Home State Basis. When the state excise tax has been filed, you will have to file a copy with us and also file an
amended Retaliatory and Fire Marshal Tax Return showing the actual excise tax number. This applies especially to Illinois
insurers but will also apply to any insurer that is subject to a state excise tax.
How do I obtain the OLHIGA assessments that my company can use as a tax offset?
The OLHIGA Offset can only be used against the Excise Tax on Oregon Form 20-INS. You may call us from 8 a.m. to 5 p.m.
Pacific time or e-mail us at any time to obtain a listing of any assessments that can be used as a tax offset.

Can I get an extension to file the Oregon Insurance Tax Return?
The Insurance Division does not grant extensions; tax forms are due by the filing due date. The Insurance Division tax forms
cannot be extended even if the federal income tax or Oregon excise tax returns are extended.




440-4760 (10/09/COM/WEB)                                                                                         Tax instructions
What if Page 1 results in a refund? Should I still send in the $1,500?
If Page 1, Line 14 results in a refund, do not sent payment for the continuation of certificate of authority. A refund will be
mailed to you as returns are audited.



Return completed forms to:                 Our street address is:
Oregon Insurance Division – 4              Oregon Insurance Division – 4
P.O. Box 14480                             350 Winter Street NE, 3rd floor
Salem, OR 97309-0405                       Salem, OR 97301-3883

                                     Website: www.insurance.oregon.org



Questions:
Lynette Hadley, insurance tax analyst               OR              Shannon O’Shea, insurance tax analyst
503-947-7046                                                        503-947-7218
lynette.m.hadley@state.or.us                                        shannon.oshea@state.or.us




440-4760 (10/09/COM/WEB)                                                                                            Tax instructions
                      STATE OF OREGON
                      Department of Consumer and Business Services
                      Insurance Division
                       Amended Insurance Tax Return, Tax Year

Name                                                                                                        State of domicile

                                                                                                            Certificate of authority number

Mailing address                                                                                             NAIC number

City                                                 State                     ZIP Code                     Federal employer ID number

Contact person                                       Phone number                                E-mail

Name or address change                                                                       As presently filed                 Amended
  1.   Fire Marshal tax from Part I, Line 10                                                                                                $0
  2.   Fire Marshal prepayment paid in tax year
  3.   Fire Marshal tax due (Line 1 minus Line 2)              (45010 1154)                                   $0                            $0
  4.   Retaliatory tax from (from Part II, Line 21)                                                                                         $0
  5.   Retaliatory tax prepayment paid in tax year
  6.   Retaliatory tax due (Line 4 minus Line 5)               (44320 1152)                                   $0                            $0
  7.   Certificate of Authority Renewal                        (44110 1555)                               $1,500                        $1,500
  8.   Total taxes and fees (add Lines 3, 6, and 7) Balance due - pay this amount                         $1,500                        $1,500
       Stop at Line 8 if filing an original return, continue if filing an amended return.
  9.   Tax paid with the original return and any previously amended returns for this tax year
 10.   Refunds received for this tax year
 11.   Tax (Refund) due, (Line 8 minus Line 9, plus Line 10)
 12.   Interest (.667% for each month not paid)                                                  (44320 0800)
 13.   Penalty (10% penalty)                                                                     (44320 0500)
 14.   Balance (Refund) due (add Lines 11, 12, and 13)

                                                                  Affidavit
State of                                               County of                                                          SS.


       (Name - please print)                     (Title)*                      (Name - please print)                             (Title)*
of the above named insurer, being duly sworn, each for himself/herself declares:
        1. That he/she is familiar with the matters to which the above return refers;
        2. That he/she is duly authorized to make, and does make, the following declaration on behalf of the insurer; and
        3. That the above return is a full and true statement of the matters described therein, according to his/her best
           knowledge, information, and belief.


                                                                          *At least one signatory must be an officer of the insurer.
       Subscribed and sworn to before me this                              day of                                  , 20             .
       Notary Public in and for the state of                                        My commission expires

             Please use notary seal in this area ONLY
                                                                          Notary signature
                                                                                      FOR DCBS USE ONLY
                                                                               Amount      Voucher #    Date sent




440-4760 (10/09/COM/WEB)                                             Page 1 of 3
Name                                                                                                         NAIC number
0                                                                                                            0


Part I - State Fire Marshal Tax (P and C Companies Only) - Amended
Premiums and dividends included in Part I, Line 1 for insurance covering the PERIL OF FIRE, use indicated statutory percentages
of amounts by Line from Oregon Exhibit of Insurer’s Annual Statement.
Enter amended amounts. If no change, enter original amounts.
                                              (1)                  (2)                (3)               (4)               (5)
                                         Gross direct premiums     Dividends paid
                                        written on Oregon risks,    or credited to
                                       less return premiums and     policyholders        Direct premiums
                                         premiums on policies         on direct           less dividends     Multiply by   Taxable portion
                                                not taken            Oregon risks          (1) minus (2)      the factor      (3) x (4)

  1.   Fire                                                                                           $0       100%                     $0
  2.   Farmowners multiple peril                                                                      $0        65%                     $0
  3.   Homeowners multiple peril                                                                      $0        65%                     $0
  4.   Commercial multiple peril                                                                      $0        50%                     $0
  5.   Inland marine                                                                                  $0        20%                     $0
  6.   Auto physical damage                                                                           $0        8%                      $0
  7.   Aircraft physical damage                                                                       $0        8%                      $0
  8.   Other                                                                                          $0                                $0
  9.   Total (add Lines 1 through 8)                                                                                                    $0
 10.   Fire Marshal tax. 1.0% of Line 9, Column 5. Number will be entered on Part II, Line 16.                                          $0



Part II - Retaliatory Tax                                                                      As presently filed          Amended
HOME STATE BASIS:
  1. Annual or continuation fee
  2. Filing annual statement
  3. Agent appointment fees paid by insurer (Schedule C)
  4. State fraud fees or assessments
  5. Other fees:
  6. Other fees:
  7. Total fees (add Lines 1 through 6)                                                                        $0                      $0
  8. Premium or privilege tax                                      X                 %                                                 $0
  9. Income or excise tax
 10. Other taxes:
 11. Other taxes:
 12. Total taxes (add Lines 8 through 11)                                                                      $0                      $0
 13. Total Home State Basis (add Lines 7 and 12)                                                               $0                      $0

OREGON BASIS:
 14.   Oregon Corporation Excise Tax (Form 20-INS, Line 29)
 15.   WCD Assessment (Schedule B, Line 9)                                                                                             $0
 16.   Oregon Fire Marshal Tax (Part I, Line 10)                                                                                       $0
 17.   Assessment paid to fund operations of Oregon Insurance Division
 18.   Oregon Medical Insurance Pool (OMIP) Assessment
 19.   Certificate of Authority renewal fee                                                                $1,500                 $1,500
 20.   Total Oregon Basis (add Lines 14 through 19)                                                        $1,500                 $1,500
 21.   Retaliatory Tax (Line 13 minus Line 20. If negative, enter -0-)                                         $0                     $0
       Number will be entered on Line 4 of Summary.




440-4760 (10/09/COM/WEB)                                               Page 2 of 3
                      STATE OF OREGON
                      Department of Consumer and Business Services
                      Insurance Division
                      Schedules A and B
Name                                                                                                     NAIC number
                                                                                                     0                                      0
                                  Schedule A - Report of Premium by Insurer - Amended
       P and C Companies                                                                 As presently filed            Amended
  1. Total direct premiums from the state page of the
     annual statement, Column 1, Line 34
  2. Longshoreman and harbor workers, Jones Act

       L and H Companies
  3. Life insurance premiums from the state page of the
     annual statement, Column 5, Line 1
  4. Annuity considerations from the state page of the
     annual statement, Column 5, Line 2
  5. Total accident and health premiums from the
     state page of the annual statement, Column 5, Line 26

       Health Care Service Contractors
  6. Health premiums in Oregon from Column 1, Line 12, Page 30,
     Exhibit of Premiums, Enrollment and Utilization of the annual statement

       Schedule B - Workers' Compensation Premium Fund Assessment Paid by Insurer - Amended
                                               (INSURANCE AND FINANCE FUNDS)
                                       Enter amended amounts. If no changes, enter original amounts.
                         (1)                           (2)                            (3)                                   (4)
                                                                                                                Actual payments made net
                                                                                                                of any prior overpayments
                 Assessment period                         Date                     Amount of                        used to reduce
              (Ended quarter and year)                     paid                     assessment                       this assessment
  1.
  2.
  3.
  4.
  5.
  6.
  7.        Total payments (add Lines 1 through 6)                                                                                      $0
  8.        List any workers’ compensation assessment refunds received during the calendar year
  9.        Total actual net assessment payments in calendar year (Line 7 minus line 8)                                                 $0
            Number will be carried to Part II, Line 15

                                         Schedule C - Agent Appointments - Amended
Complete Schedule C only if your domicile state charges agent appointment fees.

Agents that were authorized to do business for your company in Oregon                    As presently filed            Amended
       Number of agents initially appointed in tax year:

       Number of agents terminated in tax year:

If your domicile state charges a renewal fee each year, please provide the number of agents authorized to do business in Oregon that
were active in the tax year. Please provide the number of agents who are Oregon residents and agents who are not Oregon residents.

                                                                                         As presently filed            Amended
       Number of Oregon residents:
       Number of non-Oregon residents:
       Total number of active agents
440-4760 (10/09/COM/WEB)                                          Page 3 of 3

				
DOCUMENT INFO
Description: Federal Income Tax Extension Form document sample