Form 63-22 - Premium Excise Return For Domestic Insurance Companies - 1998
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1
2Form 63-22
1998
Premium Excise Return for Domestic Insurance
Massachusetts
Companies (Except Life Companies and Companies
Department of
with Respect to Ocean Marine Business)
Revenue
For calendar year 1998 or taxable year beginning
, 1998 and ending
, 19
Name of company
Federal Identification number
Mailing address
DOR Use Only
Name of treasurer
Has the Federal Government changed your taxable income for any prior year which has not yet been reported to Massachusetts?
Yes
No.
If “Yes,” report such change on Form 355FC within three months after the final federal determination.
Computation of Excise
Attach a copy of Schedule T and Underwriting and Investment Exhibit of NAIC Annual Statement
Use whole dollar method
Income
¨ $_______________ × .0228 (2.28%) = ¨1
11 Taxable premiums (Part I, line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
12 Gross investment income (Part II, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ $_______________ × .01 (1%) = . . . . . ¨2
$
13 Other (Fair Plan and Crime Prevention disbursement received) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨3
$
14 Excise due before credits.
Add lines 1, 2 and 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
$
Credits
15 Enter 10% of Massachusetts Life and Health Insurance Guaranty Association assessment paid
in the prior years (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨5
$
16 Economic Opportunity Area Credit (Schedule EOA, line 9). If this credit was claimed on Form 63-29A,
do not claim it on this form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨6
$
17 Full Employment Credit (Schedule FEC). If this credit was claimed on Form 63-29A, do not claim it on this form . . . . . . . . . ¨7
$
Excise After Credits
18 Excise due before voluntary contribution. Subtract the total of lines 5, 6 and 7 from line 4. Not less than “0” . . . . . . . . . . . . . . . 8
$
19 Voluntary contribution for endangered wildlife conservation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨9
$
10 Total excise plus voluntary contribution. Add line 8 and line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨10
$
Payments
11 1997 overpayment applied to 1998 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨11
$
12 1998 Massachusetts estimated tax payments (do not include amount from line 11) ¨12
$
13 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨13
$
14 Total payments. Add lines 11, 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
$
Refund or Balance Due
15 Amount overpaid. Subtract line 10 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
$
16 Amount overpaid to be credited to 1999 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . ¨16
$
17 Amount overpaid to be refunded. Subtract line 16 from line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨17
$
18 Balance due. Subtract line 14 from line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
$
19 M-2220 penalty ¨$ _______________________ ; Other penalties ¨ $ ______________________ . . . . . . . . Total penalty 19
$
20 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨20
$
21 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨21
$
22 Are net direct premiums so reported in lines 1 and 3 of Part I?
Yes
No.
23 Have all dividends claimed as a deduction in line 4 of Part I been included as taxable premiums
on this return or on a previous Massachusetts return?
Yes
No.
24 If the answer to line 22 or line 23 is “No,” please explain ______________________________________________________________________________
Declaration
Under the penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowl-
edge and belief, it is true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has knowledge.
Signature of appropriate corporate officer (see instructions)
Social Security number
Title
Date
Individual or firm signature of preparer
Employer Identification number
Address
Date
¨
If you are signing as an authorized delegate of the appropriate corporate officer, check here
and attach Massachusetts Form M-2848, Power of Attorney.
Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204. Make check or money order payable to the Commonwealth of
Massachusetts.
Form Code 369 Tax Type 0119
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