OFFICE OF COMMISSIONER OF INSURANCE COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER•COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner 2 Martin Luther King Jr., Dr., Suite 916, West Tower, Atlanta, GA 30334 Phone: 404-656-7553 www.oci.ga.gov PREMIUM TAX 2011 STATEMENT IN SUPPORT OF CLAIM FOR RETALIATORY TAX CREDITS GID-015-PT SEP11 COMPANY NAME (same as GID-15) NAIC # O.C.G.A. §33-8-7, deduction of Retaliatory Tax paid to another state. Any insurance company, corporation or association domiciled in this state and issuing insurance policies on fire, lightning, extended coverage and windstorm, which policies cover property within this state, may deduct any retaliatory tax actually paid to another state from the Georgia taxes due for the tax year for which such retaliatory tax was paid and only at the time when such Georgia taxes for that year are paid and upon furnishing proof of payment of such retaliatory tax to the Commissioner. A B C State to which retaliatory tax has been paid Period for which retaliatory tax was assessed and date paid – Attach proof of payment Amount of normal tax imposed by foreign state $ Total Retaliatory Tax Paid (Transfer to Form GID-012-PT, Line 6) D Amount of retaliatory tax charged by reason of foreign state’s statute and for which you claim credit $ $ INSTRUCTIONS 1. The credit for retaliatory taxes paid to other states may be claimed only by companies domiciled in the State of Georgia and issuing policies on fire, lightning extended coverage and windstorm which cover property within the State of Georgia. If your company does not qualify, please do not complete Form GID-015PT. 2. Column A – Name of state to which retaliatory tax has been paid. Do not list any states to which you have not actually paid retaliatory taxes. 3. Column B – Period in which retaliatory tax was accrued and date retaliatory tax was paid. Credits are only allowed for the current year. You must a ttach proof of payment. If tax has not been paid, no credit is allowed. 4. Column C – Amount of tax which would normally be charged by the state listed in Column A. Provide reconciliation. 5. Column D – Amount of retaliatory tax charged by foreign state for which you are claiming credit. Provide proof of payment and reconciliation. 6. Total Column D – Calculate the total credit to be claimed for retaliatory taxes paid to other states. Transfer this amount to Line 6 on Form GID-012-PT. 7. Incomplete forms will be returned. NOTE: If you have questions regarding the completion of this form, please contact the Premium Tax Unit of the Georgia Ins urance Department at 404-656-7553. E-mail: premiumtax@oci.ga.gov This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs o r services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com