Free Semi-Annual Premium Tax Form for Self-Insurers - Idaho

STATE OF IDAHO INDUSTRIAL COMMISSION P.O. BOX 83720 BOISE, ID 83720-0041

SEMI-ANNUAL REPORT 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 10) 3. Premium Tax Due (IC Form 4010A, Line 12)

$ _________________ $ _________________

$ _________________ 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 is due within 30 days after February 1 (by March 3) for the last six months of the preceding year, and within 30 days after July 1 (by July 31) 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 1 depending on the reporting period. WHITE COPY - INDUSTRIAL COMMISSION
IC 4010, REVISED 04/08 YELLOW COPY - TAXPAYER