STATE OF IDAHO |
SEMI-ANNUAL WORKERS' COMPENSATION |
INDUSTRIAL COMMISSION |
TAX REPORT FOR SELF-INSURED EMPLOYERS |
P.O. BOX 83720 |
|
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: _________________________________________________________________________
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% |
% |
2% |
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.
