Form IB-34 Fillable Installment Payment
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(Add Lines 10 11a and 11b) (Add Lines 16 17a and 17b) (Add Lines 4 5a and 5b) (Add Lines 6 12 and 18 If amount on either of these lines is less than 19 $ (be applied to subsequent installments) (City) (Date) (DOR Use Only) (Federal Employer ID Number) (Fill in circle if applicable: Payment has been made through electronic funds transfer (EFT) Unchecked (From prior Form IB 33 or prior installment form) (From prior Form IB 33 or prior installment form) (From prior Form IB 33 Schedule B Part 3 Line 5) (From prior Form IB 33 Schedule C Line 4) (From prior Form IB 33 Schedule F Line 14) (Installment Due Date (MM DD YY) (interest rate and penalty information) (Legal Name (First 35 Characters) (Legal Name) (Line 14 minus Line 15 If less than zero any remaining overpayment (Line 2 minus Line 3 If less than zero any remaining overpayment should (Line 8 minus Line 9 If less than zero any remaining overpayment should (Mailing Address) (NAIC Number) (Name of Contact Person) (NCDOR ID Number) (NCDOR ID) (Phone Number) (See www dornc com for current (See www dornc com for currentinterest rate and penalty information) (State of Domicile) (State) (Title) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (undefined) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS) (Zip Code) 1 Total Gross Premium Tax Liability 10 Net Insurance Regulatory Charge Due 11 a Penalties 12 Total Insurance Regulatory Charge Installment Due 13 Additional Tax on Property Coverage Contracts 14 Additional Property Coverage Tax Installment Due 16 Net Additional Property Coverage Tax Due 18 Total Additional Property Coverage Tax Installment Due 19 Total Installment Due 2 Gross Premium Tax Installment Due 3 Overpayment of Gross Premium Tax to be Applied as Credit 4 Net Gross Premium Tax Installment Due 5 a Penalties 6 Total Gross Premium Tax Installment Due 7 Total Insurance Regulatory Charge Liability 8 Insurance Regulatory Charge Installment Due 9 Overpayment of Insurance Regulatory Charge to be Applied as Credit a Penalties b Interest b Interest be applied to subsequent installments ) City State Zip Code complete this form; installment payments are not required ) Computation of Gross Premium Tax Installment (If prior total gross premium tax liability was less than $10 000 do notPart 1 continued on Page 2 Contracts to be Applied as Credit Date: DOR Use Only Federal Employer ID Number Fill in circle if applicable: Payment has been made through electronic funds transfer (EFT) I certify that to the best of my knowledge this return is accurate and complete IB 34 Installment PaymentWeb Property and Casualty Companies Installment Due Date (MM DD YY) Installments are due April 15th June 15th and October 15th of each taxable year interest rate and penalty information) Legal Name (First 35 Characters) Mailing Address Multiply Line 1 by 33 1/3% ( 3333) Multiply Line 13 by 33 1/3% ( 3333) Multiply Line 7 by 33 1/3% ( 3333) N C Department of Revenue Insurance Premium Tax Unit P O Box 25000 Raleigh NC 27640 0300 NAIC Number Name of Contact Person Phone Number State of Domicile NCDOR ID NCDOR ID Number North Carolina Department of Revenue Overpayment of Tax on Property Coverage Page 2 IB 34 Web 1 12 Legal Name Part 2 Computation of Insurance Regulatory Charge Installment Part 3 Computation of Additional Property Coverage Tax Installment Part 4 Amount of Installment Due should be applied to subsequent installments ) Signature: Title: Your check or money order must be in the form of U S currency from a domestic bank zero do not include in total due )