Form Ic 4010 – Fill Out and Use This PDF

BOISE, ID 83720-0041

Street Address: 11321 W. Chinden Blvd, Bldg. #2; Boise, ID 83714

FOR PERIOD ENDING

Self-Insurer's Name: ________________________________________________________________

Premium Tax Contact Person: ________________________________________________________

Telephone: _________________ Fax: ________________________ Toll Free:__________________

Address: _________________________________________________________________________

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.