Form IB-54 "Installment Payment for Self-insured Workers Compensation Group, Health Maintenance Organization, Hospital or Dental Corporation" - North Carolina

What Is Form IB-54?

This is a legal form that was released by the North Carolina Department of Revenue - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the North Carolina Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form IB-54 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Revenue.

ADVERTISEMENT
ADVERTISEMENT

Download Form IB-54 "Installment Payment for Self-insured Workers Compensation Group, Health Maintenance Organization, Hospital or Dental Corporation" - North Carolina

677 times
Rate (4.4 / 5) 34 votes
IB-54
Web
Installment Payment for:
1-18
Fill in applicable circle:
Self-Insured Workers’ Compensation Group
Health Maintenance Organization
Hospital or Dental Service Corporation
DOR Use Only
Installment Due Date
(MM-DD-YY)
Legal Name (First 35 Characters)
(USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Federal Employer ID Number
Mailing Address
City
State
Zip Code
Name of Contact Person
Phone Number
State of Domicile
NAIC Number
Fill in circle if applicable:
Payment has been made through electronic funds transfer (EFT)
Part 1.
Computation of Gross Premiums Tax Installment
(If prior total gross premiums tax liability was less than $10,000, do not
complete this form; installment payments are not required.)
,
,
,
.
1. Total Gross Premiums Tax Liability
00
1.
(From prior Form IB-53, Part 1, Line 4)
,
,
,
.
2. Gross Premiums Tax Installment Due
2.
00
Multiply Line 1 by 33 1/3% (.3333)
,
,
,
.
3. Overpayment of Gross Premiums Tax to be Applied as Credit
3.
00
(From prior Form IB-53 or prior installment form)
,
,
,
.
4. Net Gross Premiums Tax Installment Due
4.
(Line 2 minus Line 3. If less than zero, any remaining
00
overpayment should be applied to subsequent installments.)
,
,
.
.
(See www.ncdor.gov for current
5. a. Penalties
b. Interest
00
00
interest rate and penalty information)
,
,
,
.
$
6. Total Gross Premiums Tax Installment Due
6.
00
(Add Lines 4, 5a and 5b)
Part 2.
Computation of Insurance Regulatory Charge Installment
,
,
,
.
7. Total Insurance Regulatory Charge Liability
7.
00
(From prior Form IB-53, Part 2, Line 14)
,
,
,
.
8. Insurance Regulatory Charge Installment Due
00
8.
Multiply Line 7 by 33 1/3% (.3333)
,
,
,
.
9. Overpayment of Insurance Regulatory Charge to be
Applied as Credit
9.
00
(From prior Form IB-53 or prior installment form)
,
,
,
.
10. Net Insurance Regulatory Charge Installment Due
00
10.
(Line 8 minus Line 9. If less than zero, any remaining overpayment
should be applied to subsequent installments.)
,
.
,
.
(See www.ncdor.gov for current
11. a. Penalties
b. Interest
00
00
interest rate and penalty information)
,
,
,
.
$
12. Total Insurance Regulatory Charge Installment Due
12.
00
(Add Lines 10, 11a and 11b)
Part 3.
Amount of Installment Due
,
,
,
.
13. Total Installment Due
$
(Add Lines 6 and 12. If amount on either of these lines is less than
13.
00
zero, do not include in total due.)
Signature:
Title:
Date:
I certify that, to the best of my knowledge, this return is accurate and complete.
Installments are due April 15th, June 15th and October 15th of each taxable year.
Your check or money order must be in the form of U.S. currency from a domestic bank.
N.C. Department of Revenue, Insurance Premiums Tax Unit, P.O. Box 25000, Raleigh, NC 27640-0300
Page of 2