STATE OF IDAHO INDUSTRIAL COMMISSION P.O. BOX 83720 BOISE, ID 83720-0041 SEMI-ANNUAL WORKERS' COMPENSATION TAX REPORT FOR SELF-INSURED EMPLOYERS Street Address: 700 S Clearwater Lane Boise, ID 83712 FOR PERIOD ENDING_______________ Self-Insurer's Name ________________________________________________________________ Premium Tax Contact Person ________________________________________________________ Telephone _________________ Fax ________________________ Toll Free __________________ Address _________________________________________________________________________ City _____________________________________________ State ________ Zip Code __________ 1. Total Gross Wages (IC Form 4010A, Line 1) 2. Net Premium Equivalent (IC Form 4010A, Line 13) 3. Tax Rate 2.0% 4. Premium Tax Due (IC Form 4010A, Line 15) $ _________________ $ _________________ % _________________ $ _________________ *Minimum Tax Due = $75.00 AFFIDAVIT ________________________________, being first duly sworn, deposes and states that s/he is a corporate officer, with the title of ___________________________, that this report is made under the provisions of Section 72-524, Idaho code, and under penalty of perjury; that the foregoing statement contains a full, true and accurate report of the gross wages, premium tax equivalent, and premium taxes due for the period set forth above. _____________________________________________ (Signature of Corporate Officer) Subscribed and sworn to before me this _____ day of ___________________________, ________ NOTARY PUBLIC ____________________________ Residing at _________________________________ My Commission Expires _______________________ This report must be completed even if you have NONE and it is due within 30 days after February 1 (in this office no later than March 3rd) for the last six months of the preceding year, and within 30 days after July 1 (in this office no later than July 31st) for the first six months of the current year. LATE PAYMENT PENALTY - 10% of the original amount due times the number of ten-day periods or portions thereof which have elapsed since March 3 or July 31 depending on the reporting period. IC 4010, REVISED 05/15 ORIGINAL TO THE INDUSTRIAL COMMISSION RETAIN A COPY FOR YOUR RECORDS American LegalNet, Inc. www.FormsWorkFlow.com