Nevada Department of Taxation by suchenfz


									Nevada Department of Taxation                                                Due Date                    Tax Identification No:       ____________
1550 College Parkway, Rm 115                                                                                        Federal ID: _______________________
Carson City, NV 89706-7921                                            March 15, 2011                            Premium Tax: _______________________
Phone: (775) 684-2000                                                                                          Retaliatory Tax: _______________________
Fax: (775) 684-2020                                                                                           Total Remittance: _______________________


                                                                                                         Departmental Use Only

                                                                                                              Amount: _______________________________
                                                                                                          Check No: _______________________________
                                                                                                         Date Rec’d: _______________________________
                                                                                                              Initials: _______________________________

1. Total Premiums/Consideration (Must agree with Schedule 1, Line 6A)                                                            1.

2. Gross Premium Tax (3.5% of Line 1 or 2% for RRG, if qualified, (Must agree with Schedule 1, Line 12A)                         2.

3a. Home Office Credit, if qualified (NRS 680B.050) 50% or .5 of Line 2 (Form PT-04 and required documents must be attached)     3a.

3b. Amount of Ad Valorem Taxes Paid, if qualified for Home Office Credit (NRS 680B.050.)                                         3b.

3c. Max Credit Allowed                                                                                                           3c.

3d. Allowable Home Office Credits                                                                                                3d.

4. Subtotal of Premium Tax Due for Calendar Year 20010 (Line 2 minus Line 3d)                                                    4.

5. Life/Health Guaranty Association Offset (NRS 686C)                                                                            5.

6. Property/Casualty Guaranty Association Credit (NRS 687A)                                                                      6.

   A. Total Overpayments applied from previous years                                                      A

   B. Total Overpayments refunded by Nevada in 2010                                                       B

7. Net Premium Tax Due                                                                                                           7.

8. Penalty (See Instructions for rate)                                                                                           8.

9. Daily Interest. Premium Tax Due (Line 7) multiplied by .00049315068 times the number of days late                             9.

10. Total Premium Tax Due (Line 7 plus Lines 8 and 9)                                                                            10.

 If line 10 results in an overpayment, the overpayment may be applied to next years taxes or the overpayment may be

      Amount to be refunded

                                                NRS REQUIRES THIS RETURN MUST BE SIGNED
I hearby declare under penalty of perjury that this premium tax report (including any accompanying schedules and statements) has been examined by
me and is true, correct and complete report.

Signature of Taxpayer or Authorized Agent                     Printed Name of Taxpayer or Authorized Agent                Date          Telephone

                                                                                                                                       Revised 2-2-09
Nevada Department of Taxation
Schedule 1
Statement of Premium Tax and Fees on Retaliatory Basis
For Year Ending December 31, 2010

Do NOT Include Industrial Insurance
                                                                                      (A)            (B)
                                                                                      Nevada Basis   State of Inc

1. Gross Annual Premium/Considerations
2. Plus: Current dividends applied to provide paid-up additions or to reduce
   Endowments or premium-paying periods
3. Dividends paid or credited to policy holders
Less: Deductions, categorized by class of Business according to applicable tax rate
4. Net premiums or considerations received from policies or contracts issued in
   Connection with plans qualified or exempt under US Internal Revenue Code
   (See instructions).
5. Back End Annuities
   Other ____________________________________________________________
   Other ____________________________________________________________
6. Net Taxable Premiums (Line 1 plus Line 2 less Lines, 3, 4 and 5)
7. Taxes Payable (according to applicable tax rate for Nevada 3.5% or 2% for RRG)

Lines 8 through 11, Additional Taxes and Assessments (Include Fire Marshall, Ocean
Marine and/or other state or municipal tax that is levied on a Nevada company doing
business in your state.)
8. ________________________________$______________@_______________%
9. ________________________________$______________@_______________%
10. _______________________________ $______________@_______________%
11. Other Tax _______________________$______________@_______________%
12. Total Taxes (Line 7 through 11)

The fees listed below are for retaliatory calculation purposes only.

13.   Filing Annual Statement (Nevada $25)
14.   Annual Licensing Fee (Nevada $2,450)
15.   Annual Naic Fee (Nevada $26)
16.   Filing Charter Documents (Nevada $10 each)
17.   Filing Power of Attorney (Nevada $5)
18.   Filing any other certificate form (Nevada $10 each)
19.   Filing Certificate of Compliance (Nevada -0-)
20.   Agent Licenses And Renewals (Nevada $15 - $125)
21.   Filing Rates and Forms                   _______________ @ $25 each
22.   Filing Riders and Endorsements           _______________ @ $10 each
23.   Total all Fees/Charges (Line 13 through 21)
24.   Total Taxes and Fees (Line 12 and Line 22)
25.   Retaliatory Assessment (Line 24, Column B minus Line 24, column A) (Remit
      Retaliatory Assessment to the Department of Taxation)

                                                                                                     Revised 2-2-09
Nevada Department of Taxation


Do not include Industrial Insurance (Workers Compensation)

This form is to be used if you paid under $2,000 in Insurance Premium Tax during the previous year. The Nevada premium tax rate is 3.5% or 2% for Risk Retention
Groups, if qualified. (Retaliatory statutes, NRS 680A.330 requires you to use the higher tax rate charged by your domiciliary state.)

Schedule 1

Line 1 Gross Premiums/Considerations Defined as all direct premiums written during the year (including policy, membership and other fees and assessments) and all
considerations for insurance, bail, or annuity contracts received on account of policies and contracts covering property or risks located, resident or to be performed in
Nevada, less returned premiums/considerations only. Considerations received during the year for deferred annuity contracts, if not included in premium, must be
included as gross premiums. Considerations received under an election pursuant to NRS 680B.025(2) are deductible at line 5. Returned considerations are the lesser of
the aggregate of considerations returned or the amount paid out to the contract owner. Both the gross amounts included at line 1 and line 5 must be reduced by the
returned consideration. (Fill out schedule 2, the annuity consideration worksheet on the reverse side and attach to your annual return).

Line 3 Policy Dividends (Life Insurance) This figure should be the total dividends paid or credited to policyholders during the year.

Line 4 Federally Qualified Plans Premiums for federally qualified plans are defined as gross premiums or considerations received during the year for policies or
contracts issued in connection with retirement plans qualified or exempt under sections 401, 403, 404, 408, 457 or 501 of the US Internal Revenue Code.

Line 5 Other Deductions Entries must be fully supported by schedule and/or explanatory note. NRS680B.025(2) election deductions must be supported by a statement
by an officer of the company, under oath, declaring the date the election was first made or date the Commissioner of Insurance approved the election and a list of
annuity contract forms (title and form number) to which the election applies.

Line 7 Taxes Payable If the state of domicile taxes each class of premium at different rates, a separate schedule calculating the tax in accordance with the domiciliary
state method must be attached and the tax amount entered on line 12 only, state of inc. (do not complete lines 1 through 11).

Schedule 2

Annuity Election Information If the insurer is reporting premium tax on annuities they must choose the type of election either front end or back end, the date of
election and date election approved by Commissioner of Insurance.

Column Front End Annuities This figure should be the amount of front end annuities or back end annuity considerations that have annuitized. Interest and/or
dividends need to be included in the amount of annuities taxed on a back end basis.

Column Back End Annuites This figure should be the amount of back end annuities or annuity considerations that have not annuitized. Include dividends and
interest in this figure.

Column Total Considerations Gross Considerations (Line 3) should be the total of Qualified Retirement Plans plus Front End Annuities plus Back End Annuities and
should match the figures on the State (Nevada) page.

Annual Return

Lines 1 Total Premiums/Considerations (Must agree with Schedule 1, Line 6A)

Line 3a Home Office Credit .50% or .5 of Line 2. NRS 680B.050 provides that insurers who maintain a “home” or “regional” office may be entitled to a credit against
tax to be paid. It provides for a 50 percent credit for tax due. Each insurer claiming a home or regional home office credit must have a certified copy of the deed to the
property in the name of the insurer on file with the Department.

Line 3b Ad Valorem Taxes Enter the amount of Ad Valorem Taxes paid during the year. NRS 680B.050(1) provides for credit for ad valorem taxes actually paid upon
the home office or regional home office together with the land, as reasonably required for the convenient use of the office, upon which the home office or regional home
office is situated. Further, the insurer must provide certified copies of the billing by local authorities for the ad valorem taxes in addition to a receipt for proof of

Line 3c Enter max credit allowed. Multiply Line 2 by 80% or .80. NRS 680B.050(1) imposes a limit on the total amount of the credit that may be obtained. The
credits may not reduce the total amount of taxes payable to less than 20 percent of the amount of the gross premium taxes payable.

Line 3d Enter the available Home Office and Ad Valorem taxes credit. Add Lines 3a and 3b. Compare to line 8c. Enter the lesser of the two.

Line 4 Subtotal of Premium Tax Due Enter the net premium tax Line 2 minus Line 3d.

Line 5 Life/Health Guaranty Enter amount of Life/Health Guaranty Association Offset.

Line 6 Enter amount of Property/Casualty Guaranty Association credit.

Line A Enter the amount due to you for overpayments made in prior reporting periods for which you have received a Department of Taxation Credit Notice. Monthly
notices received from the Department are not cumulative. Do not take the credit if you have applied for a refund. NOTE: Only credits established by the Department
may be used.

Line B Enter the amount of Overpayments refunded by Nevada during the calendar year.

                                                                                                                                                   Revised 2-2-09
Line 7 Net Premium Tax Due. Enter the amount of Net Premium Tax due. Line 4 minus Lines 5 through A, plus Line B.

Line 8 Penalty If this return is not submitted/postmarked and taxes are not paid on or before the due date as shown on the face of this return, the amount of penalty due
is a) For returns with Period(s) Ending prior to and including 3/31/07 the Penalty is 10%; b) For returns with Period(s) ending 4/30/07 and after; the amount of penalty
due is based on the number of days the payment is late per NAC 360.395 (see table below). The maximum penalty is 10%.

Number of days late               Penalty Percentage                 Multiply by:
1 - 10                            2%                                 0.02
11 - 15                           4%                                 0.04
16 - 20                           6%                                 0.06
21- 30                            8%                                 0.08
31 +                              10%                                0.10

Determine the number of days late the payment is, and multiply the net tax owed (Line 7) by the appropriate rate based on the table above. The result is the amount of
penalty that should be entered. For Example, the taxes were due January 31, but not paid until February 15 so the penalty is 4%.

Line 9 Daily Interest If this return will not be postmarked and the taxes paid on or before the due date as shown on the face of this return, interest will be calculated
daily. Line 7 multiplied by .00049315068 times the number of days late.

Line 10 Total Adjusted Premium Tax Due If the calculated amount entered on this line results in a negative figure, this amount is the premium tax overpayment that
will refunded. Pursuant to NRS 680B.120 request for refund must be made within 1 year after the date such fees, charges or taxes were originally required to be paid
or within 30 days after the date of payment of any additional tax, charge or fee. If premium tax and/or retaliatory assessment are owed, make check payable to the
Department of Taxation.

                                                                                                                                                     Revised 2-2-09
Nevada Department of Taxation                                                                                 Company ID No.______________
ANNUITY CONSIDERATION WORKSHEET                                                                               Tax Year:             ______________

Company Name:______________________________


                                        Date of Election :                         Date Election Approved by Commissioner of Insurance:
         Front End Annuities
                                        Date of Election :                         Date Election Approved by Commissioner of Insurance :
         Back End Annuities

                                     Qualified Retirement                          Premium Tax Options                                     Total Considerations
                                             Plans           Front End Annuities              Back End Annuities

Annuity Considerations:
(1) Received as Direct
    Premium Written:

(2) Received as Annuity
    Deposit Funds:

(3) Gross Considerations
    (Line 1 plus Line 2):

(4) Return Considerations:

(5) Amount Remitted:

(6) Less amounts in excess of
    Considerations received:

(7) Deductible Surrenders
    (Line 5 less Line 6):

(8) Total Deduction (Line 4
    Plus Line 7):

(9) Net Considerations (Line 3
    Less Line 8):

Tax Status of Line (9):                                                                                                               Include this amount in
                                                                                                                                       Line 1, Statement of
Non-Taxable by Domicile
                                                                                                                                      Premium Tax and Fees
                                                                                                                                       on Retaliatory Basis

Non-Taxable by Nevada

                                     Include in Line 4,                                              Include in Line 5
                                  Schedule 1, Statement of                                        Schedule 1, Statement of
                                 Premium Tax and Fees on                                         Premium Tax and Fees on
                                     Retaliatory Basis                                               Retaliatory Basis

                                                                                                                                                   Revised 2-2-09
Revised 2-2-09

To top