Form 63-23 - Premium Excise Return For All Classes Of Foreign Insurance Companies - 1998
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1
21998
Form 63-23
Premium Excise Return
Massachusetts
Department of
for All Classes of Foreign Insurance Companies
Revenue
(Except Life Insurance Companies and Companies with Respect to Ocean Marine Business)
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
Organized under the laws of
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 of NAIC Annual Statement)
Income and Deduction
Use whole dollar method
¨1
11 Total net direct premiums for insurance of property or interests in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
12 Other (Fair Plan and Crime Prevention Premiums). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨2
$
13 Total income.
Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
$
14 Dividend deduction. Premiums returned or credited to policyholders as dividends (unabsorbed premium deposits)
on direct business . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨4
$
Excise
15 Amount taxable. Subtract line 4 from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
$
16 Tax at 2.28% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨6
$
17 Tax computed under retaliatory provisions (enter full amount) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨7
$
18 Applicable excise before credits. (Enter the larger of line 6 or line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
$
Credits
19 Enter 10% of Mass. and Health Insurance Guaranty Association assessment paid in the prior years (see instructions) . . . . ¨9
$
10 Economic Opportunity Area Credit (Sch. EOA, line 9). If this credit was claimed on Form 63-29A, do not claim it on this form ¨10
$
11 Full Employment Credit (Sch. FEC). If this credit was claimed on Form 63-29A, do not claim it on this form . . . . . . . . . . . . . ¨11
$
Excise After Credits
12 Excise due before voluntary contribution. Subtract the total of lines 9, 10 and 11 from line 8. Not less than “0” . . . . . . . . . . . . 12
$
13 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨13
$
14 Total excise plus voluntary contribution. Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨14
$
Payments
15 1997 overpayment applied to 1998 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨15
$
16 1998 estimated tax payments (do not include amount from line 15). . . . . . . . . . . . . . ¨16
$
17 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨17
$
18 Total payments. Add lines 15, 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
$
Refund or Balance Due
19 Amount overpaid. Subtract line 14 from line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
$
20 Amount overpaid to be credited to 1999 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . ¨20
$
21 Amount overpaid to be refunded. Subtract line 20 from line 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨21
$
22 Balance due. Subtract line 18 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
$
23 M-2220 penalty ¨$ _______________________ ; Other penalties ¨ $ ______________________ . . . . . . . . Total penalty 23
$
24 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨24
$
25 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨25
$
26 Are net direct premiums so reported in line 1?
Yes
No. Have all dividends claimed as a deduction in line 4 been
included as taxable premiums in line 1 on this return or on a previous Mass. return?
Yes
No.
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 Mass. Form M-2848, Power of Attorney.
Mail to: Mass. Department of Revenue, PO Box 7052, Boston, MA 02204. Make check or money order payable to the Commonwealth of Massachusetts.
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