Form 83-391-22-8-1-000 (Rev. 04/22)                                                                              Reset Form

                                                                Mississippi                                      Print Form
                                          Insurance Company Income Tax Return
      833912281000                                                2022
Tax Year Beginning                                                                                         Tax Year Ending  
                         mm dd yyyy                                                                                            mm dd yyyy
FEIN                                                                                  Mississippi Secretary of State ID   

Legal Name and DBA                                                                                         CHECK ALL THAT APPLY

Address                                                                                      Amended Return                 Accident and Health

                                                                                             Final Return                   Fire and Casualty

City                                                      State Zip +4                                                      Life Insurance
                                                                                             Accrual Basis

County Code                         NAICS Code                                               Receipts and  
                                                                                             Disbursements Basis 
COMPUTATION OF TAX                                                                                           (ROUND TO THE NEAREST DOLLAR)

      Combined income tax return (enter FEIN of reporting company)

1     Mississippi net taxable income (from page 2, line 17A or Form 83-310, page 1, line 5, column C)       1                                .00

2     Income tax                                                                                            2                                .00

3     Retaliatory taxes paid to other states (Mississippi corporations only; from page 4, part V, line 1)   3                                .00

4     Income tax credits (from Form 83-401, line 3 or Form 83-310, page 1, line 5, column B)                4                                .00

5     Net income tax due (line 2 minus line 3 and line 4)                                                   5                                .00

PAYMENTS AND TAX DUE

6     Overpayment from prior year                                                                           6                                .00

7     Estimated tax payments and payment with extension                                                     7                                .00

8     Total payments (line 6 plus line 7)                                                                   8                                .00

9     Net total income tax due (line 5 minus line 8)                                                        9                                .00

10   Interest and penalty on underestimated income tax payments (from Form 83-305, line 19)                 10                               .00

11   Late payment interest                                                                                  11                               .00

12   Late payment penalty                                                                                   12                               .00

13   Late filing penalty (minimum $100)                                                                     13                               .00

14   Total balance due (if line 5 is larger than line 8, add lines 9 through 13)                            14                               .00

15   Total overpayment (if line 8 is larger than line 5, subtract line 5 from line 8)                       15                               .00

16    Total overpayment credited to next year (from line 15)                                                16                               .00

     17   Total overpayment refunded (line 15 minus line 16)                                                17                               .00

                         See instructions for electronic payment options or attach check or money order for balance due. 

Form 83-391-22-8-2-000 (Rev. 04/22)
                                                         Mississippi
                                                                                                                               Page 2 
                                          Insurance Company Income Tax Return
    833912282000                                                       2022
FEIN

COMPUTATION OF NET INCOME                                                             A  MISSISSIPPI                B  COMPANY-WIDE
1    Direct premiums (except accident and 
      health premiums)                                                 .00
Less: return premiums                                                  .00      1A                        .00   1B                                          .00

2    Direct accident and health premiums                                        2A                        .00   2B                                          .00

3    Reinsurance assumed                                                        3A                        .00   3B                                          .00

4    Considerations for annuities                                               4A                        .00   4B                                          .00

5    Considerations for supplementary contracts                                 5A                        .00   5B                                          .00

6    Unearned premiums (December 31st, prior year)                              6A                        .00   6B                                          .00

7    Gross investment income                                                    7A                        .00   7B                                          .00

8    Other income                                                               8A                        .00   8B                                          .00

9    Total net income (add line 1 through line 8)                               9A                        .00   9B                                          .00

DEDUCTIONS

10  Unearned premiums (December 31st, current year)                             10A                       .00   10B                                         .00

11  Reinsurance ceded                                                           11A                       .00   11B                                         .00

12  Dividends to policy holders                                                 12A                       .00   12B                                         .00

13  Total deductions (add line 10 through line 12)                              13A                       .00   13B                                         .00

MISSISSIPPI NET TAXABLE INCOME

14  Gross income (line 9 minus line 13)                                         14A                       .00   14B                                         .00

15  Total deductions allocated and apportioned (from page 4, part III, line 23) 15A                       .00   15B                                         .00

16  Less: Mississippi net operating loss (from Form 83-155, part I, line 2)     16A                       .00   16B                                         .00

17  Net taxable income (loss) (line 14 minus line 15 and line 16; enter amount  17A                       .00   17B                                         .00
      from 17A on page 1, line 1 or Form 83-310, page 1, line 5, column C)

    Check box if return may be discussed with preparer

I declare, under penalties of perjury, that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, 
this is a true, correct and complete return. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. 

    Officer Signature and Title                                                      Date                       Business Phone

    Paid Preparer Signature                         Date                             Paid Preparer Address

    Paid Preparer PTIN                             Paid Preparer Phone          City                      State Zip Code
                                    Mail Return To: DEPARTMENT OF REVENUE  P.O. BOX 23191 JACKSON, MS 39225-3191 

Form 83-391-22-8-3-000 (Rev. 04/22)

                                                              Mississippi
                                                                                                      Page 3 
                                            Insurance Company Income Tax Return
                                                                 2022
FEIN

PART I:   EXPENSE APPORTIONMENT RATIOS                        A   MISSISSIPPI     B  COMPANY-WIDE C  MISSISSIPPI RATIO

 Applicable ratio(s) used on page 4, part IV, line 2

1     Loss adjustment expenses (direct losses)             1A                 1B                  1C .           %

2     Accident and health expenses (direct premiums and  
       reinsurance assumed)                                2A                 2B                  2C .           %
3     Other underwriting expenses (direct premiums  
       (less return premiums), annuity considerations and  3A                 3B                  3C .           %
       reinsurance assumed)
4    Investment expenses (gross investment income)         4A                 4B                  4C .           %

PART II:  DEDUCTIONS ALLOCATED                                    A   MISSISSIPPI                 B  COMPANY-WIDE

5    Losses, death benefits, accident and health 
      benefits (less applicable recoveries)
       a  Paid                                                5Aa                 .00 5Ba                        .00

       b  Unpaid at December 31st, current year               5Ab                 .00 5Bb                        .00

       c  Unpaid at December 31st, prior year                 5Ac                 .00 5Bc                        .00

6    Loss adjustment expenses allocated                       6A                  .00 6B                         .00

7    Matured endowments                                       7A                  .00 7B                         .00

8    Annuity benefits                                         8A                  .00 8B                         .00

9    Disability benefits                                      9A                  .00 9B                         .00

10  Surrender benefits                                        10A                 .00 10B                        .00

11  Payments on supplementary contracts                       11A                 .00 11B                        .00

12  Net additions to reserve funds (required by law  
      for liquidating policies at maturity)                   12A                 .00 12B                        .00

13  Commissions                                               13A                 .00 13B                        .00

14  Gross premium privilege tax                               14A                 .00 14B                        .00

15  Other allocable taxes                                     15A                 .00 15B                        .00

16  Rent, allocated                                           16A                 .00 16B                        .00

17  Agency expense (attach schedule)                          17A                 .00 17B                        .00

18  Medical and inspection fees, allocated                    18A                 .00 18B                        .00

19  Other allocable deductions (attach schedule)              19A                 .00 19B                        .00

20  Total allocable deductions                                20A                 .00 20B                        .00

Form 83-391-22-8-4-000 (Rev. 04/22)

                                                               Mississippi                                                            Page 4 
                                   Insurance Company Income Tax Return
                                                                     2022
FEIN

PART III: DEDUCTIONS APPORTIONED                                         A   MISSISSIPPI                           B  COMPANY-WIDE

21   Non-allocable loss adjustment expenses                          21A                 .00                   21B                           .00

22   Total apportioned expenses (from page 4, part IV, line 3)       22A                 .00                   22B                           .00

23   Total allocated and apportioned deductions (line 20 plus  
        line 21 plus line 22; enter on page 2, line 15)              23A                 .00                   23B                           .00

PART IV:  DEDUCTIONS APPORTIONED   (FROM ANNUAL STATEMENT) 
Expenses must be separately apportioned.  Attach supplementary pages to return as needed.

    Page Line                                           Description        A   Column (  )   B   Less Allocable                      C  Balance    
                                                                                                Expenses           Apportionable

1    Totals (total column A minus total column B)

2    Applicable expense apportionment ratio (from page 3, part I)                                                                    .       %

3    Total apportioned to Mississippi (multiply line 1, column C by  
      line 2, enter amount on page 4, part III, line 22)

PART V: RETALIATORY TAXES PAID    (MISSISSIPPI CORPORATIONS ONLY)
Itemize retaliatory taxes paid by state and attach copies of returns documenting amounts.  Attach supplementary schedules as needed. 

    A   Taxing Authority                                B   Amount         A   Taxing Authority                    B   Amount

                                                                         1  Total amounts (total amounts from  
                                                                              column B; enter amount on page  
                                                                              1, line 3)