Free DR-907 - Florida

Florida Insurance Premium Installment Payment
FEIN Florida Code
1. premium tax payable

HD/PM Date:

/
US Dollars

/

Business Partner Number

payment number 1 tax Year
due april 15

DR-907

2. surcharge a. commercial policies # _________________ x $4 b. residential policies # _________________ x $2 3. interest 4. penalty

name address City/st/Zip

5. Quarterly statement filing fee 6. Amount due

Check here if you transferred payment electronically.
Be sure to sign and date reverse side.
Mail form and remittance to: Florida department oF revenue 5050 W tennessee street tallahassee Fl 32399-0150

do not Write in the space Below

, , , , , , ,

, , , , , , ,

DR-907 R. 01/09 Cents

9100 0 20099999 0016045033 1 3999999999 0000 2

Florida Insurance Premium Installment Payment
FEIN Florida Code
1. premium tax payable

HD/PM Date:

/
US Dollars

/

Business Partner Number

payment number 2 tax Year
due June 15 (estimate premiums through June 30)

DR-907

2. surcharge a. commercial policies # _________________ x $4 b. residential policies # _________________ x $2 3. interest 4. penalty

name address City/st/Zip

5. Quarterly statement filing fee 6. Amount due

Check here if you transferred payment electronically.
Be sure to sign and date reverse side.
Mail form and remittance to: Florida department oF revenue 5050 W tennessee street tallahassee Fl 32399-0150

do not Write in the space Below

, , , , , , ,

, , , , , , ,

DR-907 R. 01/09 Cents

9100 0 20099999 0016045033 1 3999999999 0000 2

Florida Insurance Premium Installment Payment
FEIN Florida Code
1. premium tax payable

HD/PM Date:

/
US Dollars

/

Business Partner Number

payment number 3 tax Year
due october 15

DR-907

2. surcharge a. commercial policies # _________________ x $4 b. residential policies # _________________ x $2 3. interest 4. penalty

name address City/st/Zip

5. Quarterly statement filing fee 6. Amount due

Check here if you transferred payment electronically.
Be sure to sign and date reverse side.
Mail form and remittance to: Florida department oF revenue 5050 W tennessee street tallahassee Fl 32399-0150

do not Write in the space Below

, , , , , , ,

, , , , , , ,

DR-907 R. 01/09 Cents

9100 0 20099999 0016045033 1 3999999999 0000 2

Signature of Officer Complete each line using the line-by-line instructions. Line 1 Line 2 Premium Tax Payable -- enter the amount of installment payment due based upon net premiums written. Surcharge -- enter the number of commercial policies on line 2a and multiply by $4.00. enter the number of residential policies on line 2b and multiply by $2.00. Interest -- Compute any interest due with this installment payment. Interest is calculated with a floating rate. Penalty -- Compute any penalty due with this installment payment. Quarterly Statement Filing Fee -- enter your quarterly statement filing fee. Fraternal benefit societies do not file quarterly installments. prepaid limited health service insurers are not required to pay a quarterly filing fee. All other authorized insurers must pay a $250 quarterly statement filing fee. Line 6

date Amount Due -- enter the total of lines 1 through 5.

sign and date the form in the spaces provided above.

Line 3 Line 4 Line 5

Front of Form: Verify the personalized information printed on the front of the form. if you are using a blank form, enter your Fein and Florida Code in the spaces provided and print or type your name and address in the space under payment due date. Check the box if you have sent your payment electronically.

Rule 12B-8.003 Florida Administrative Code Effective 01/09

Signature of Officer Complete each line using the line-by-line instructions. Line 1 Line 2 Premium Tax Payable -- enter the amount of installment payment due based upon net premiums written. Surcharge -- enter the number of commercial policies on line 2a and multiply by $4.00. enter the number of residential policies on line 2b and multiply by $2.00. Interest -- Compute any interest due with this installment payment. Interest is calculated with a floating rate. Penalty -- Compute any penalty due with this installment payment. Quarterly Statement Filing Fee -- enter your quarterly statement filing fee. Fraternal benefit societies do not file quarterly installments. prepaid limited health service insurers are not required to pay a quarterly filing fee. All other authorized insurers must pay a $250 quarterly statement filing fee. Line 6

date Amount Due -- enter the total of lines 1 through 5.

sign and date the form in the spaces provided above.

Line 3 Line 4 Line 5

Front of Form: Verify the personalized information printed on the front of the form. if you are using a blank form, enter your Fein and Florida Code in the spaces provided and print or type your name and address in the space under payment due date. Check the box if you have sent your payment electronically.

Rule 12B-8.003 Florida Administrative Code Effective 01/09

Signature of Officer Complete each line using the line-by-line instructions. Line 1 Line 2 Premium Tax Payable -- enter the amount of installment payment due based upon net premiums written. Surcharge -- enter the number of commercial policies on line 2a and multiply by $4.00. enter the number of residential policies on line 2b and multiply by $2.00. Interest -- Compute any interest due with this installment payment. Interest is calculated with a floating rate. Penalty -- Compute any penalty due with this installment payment. Quarterly Statement Filing Fee -- enter your quarterly statement filing fee. Fraternal benefit societies do not file quarterly installments. prepaid limited health service insurers are not required to pay a quarterly filing fee. All other authorized insurers must pay a $250 quarterly statement filing fee. Line 6

date Amount Due -- enter the total of lines 1 through 5.

sign and date the form in the spaces provided above.

Line 3 Line 4 Line 5

Front of Form: Verify the personalized information printed on the front of the form. if you are using a blank form, enter your Fein and Florida Code in the spaces provided and print or type your name and address in the space under payment due date. Check the box if you have sent your payment electronically.

Rule 12B-8.003 Florida Administrative Code Effective 01/09

DR-907N R. 01/09
Rule 12B-8.003 Florida Administrative Code Effective 01/09

Instructions for Filing Insurance Premium Installment Payment (Form DR-907)
use black ink. example a - handwritten example B - typed

0 1

2 3 4 5 6 7 8 9

0123456789

When is the installment payment due and payable? installments of tax are due and payable on april 15, June 15, and october 15 of each year. a final payment of tax due for the year must be made at the time the taxpayer files the return (DR-908) for the year. An installment will be considered timely filed if it is postmarked by the U.S. postal service on or before the applicable due date. if the due date falls on a saturday, sunday, or state or federal holiday, the installment will be considered timely filed if it is postmarked the next business day. What are the installment payments based on? installments are based on the estimated gross amount of receipts of insurance premiums or assessments received during the immediately preceding calendar quarter. the second quarter installment due June 15 (not July 15) requires the estimate to be through June 30. any taxpayer paying for each installment, 27 percent of the amount of the annual tax reported on the preceding year's Form DR-908 (Line 11 minus line 9 and line 10), shall not be subject to the installment penalty. Penalty for Underpayment/Late Filing of Insurance Premium Tax Installment Payments: any taxpayer who fails to report and timely pay any installment of tax, who estimates any installment of tax to be less than 90 percent of the amount finally shown to be due in any quarter, and/or who fails to report and timely pay any tax due with the final return is subject to a penalty of 10 percent on any underpayment of taxes or delinquent taxes due and payable for that quarter and/or on any delinquent taxes due and payable with the final return. Interest for Underpayment/Late Filing of Insurance Premium Tax Installment Payments: interest accrues when a taxpayer fails to pay any amount due on or before the due date. A floating rate of interest applies to underpayments and late payments of tax. the rate is updated January 1 and July 1 of each year by using the formula established in s. 213.235, Florida statutes (F.s.). For current and prior year interest rates, visit our internet site or contact taxpayer services (see "For information and Forms").

Where to Mail Your Form and Payment: mail your completed dr-907 form and payment to: Florida department of revenue 5050 W tennessee street tallahassee Fl 32399-0150 Electronic Funds Transfer If you paid $20,000 or more in tax during the State of Florida's prior fiscal year (July 1, 2007 ­ June 30, 2008), you are required to remit taxes by electronic funds transfer (eFt). please visit the department's internet site at www.myflorida.com/dor to enroll for eFt. For more information, call the Department at 800-352-3671. For Information and Forms: information and forms are available on our internet site at



www.myflorida.com/dor

to speak with a department of revenue representative, call taxpayer Services, Monday through Friday, 8 a.m. to 7 p.m., ET, at 800-352-3671. persons with hearing or speech impairments may call our tdd at 800-367-8331 or 850-922-1115. to receive forms by mail: · Order multiple copies of forms from our Internet site at www.myflorida.com/dor/forms or · Mail form requests to: distribution Center Florida department of revenue 168A Blountstown Hwy Tallahassee FL 32304-3761 For a written reply to tax questions, write: taxpayer services Florida department of revenue 5050 W tennessee st Bldg l tallahassee Fl 32399-0112

detach here

Change of Address or Business Name
Complete this form, sign it, and mail it to the department if: · The address below is not correct. · The business location changes. · The corporation name changes. mail to: Florida department of revenue 5050 W tennessee st tallahassee Fl 32399-0100
CHANGE IN New Location Address

Fein of entity Business location_________________________________________________________ City____________________________________ state_______ Zip__________________ Business telephone (_______) ___________________ County_____________________ in Care of_________________________________________________________________ mailing address___________________________________________________________ New Mailing Address City____________________________________ state_______ Zip__________________ owner's telephone (_______) ___________________ County______________________ New Business dBa______________________________________________________________________ Name New _________________________________________________________________________ Corporation Name

______________________________________________________ SignatureofOfficer(Required) Date

9100 0 20099999 0016045999 6 3999999999 0000 2