Form 63-22 - Premium Excise Return For Domestic Insurance Companies - 2000
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1
2Form 63-22
2000
Premium Excise Return for
Massachusetts
Domestic Insurance Companies
Department of
Revenue
(Except Life Companies and Companies with Respect to Ocean Marine Business)
For calendar year 2000 or taxable year beginning
2000 and ending
Name of company
Federal Identification number
Mailing address
DOR use only
Name of treasurer
Check applicable gross investment income tax rate
❿
.01
.008
.006
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 CA-6, Application for Abatement/Amended Return, 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.
Income
Use whole dollar method
× .0228 (2.28%) = ❿ 1
11 Taxable premiums (Part I, line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ $_______________
$
12 Gross investment income (Part II, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ $_______________ × .applicable rate =❿ 2
13 Other (Fair Plan and Crime Prevention disbursement received) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 3
14 Excise due before credits.
Add lines 1, 2 and 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Credits
15 Retaliatory surtax credit (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5
16 Enter 1.5% of company’s total capital contributions in excess of the full proportionate share in investment in the
Massachusetts property and casualty initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 6
17 Credit against premium excise. Add lines 6 and 7. Enter total here, but do not exceed the amount in line 1 . . . . . . . . . . . . . . . 7
18 Enter 10% of Massachusetts Life and Health Insurance Guaranty Association assessment paid previously . . . . . . . . . . . . . ❿ 8
19 Economic Opportunity Area Credit (Schedule EOA, line 9). If claimed on Form 63-29A, do not claim it here. . . . . . . . . . . . . ❿ 9
10 Full Employment Credit (Schedule FEC). If this credit was claimed on Form 63-29A, do not claim it here. . . . . . . . . . . . . . ❿ 10
11 Total credits. Add lines 7, 8, 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 11
Excise After Credits
12 Excise due before voluntary contribution. Subtract line 11 from line 4. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 13
14 Total excise plus voluntary contribution. Add line 12 and line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 14
Payments
15 1999 overpayment applied to 2000 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15
$
16 2000 Massachusetts estimated tax payments (do not include amount from line 15) ❿ 16
17 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 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 2001 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . ❿ 20
21 Amount overpaid to be refunded. Subtract line 20 from line 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 21
22 Balance due. Subtract line 18 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
23 M-2220 penalty ❿!$_______________________ ; Other penalties ❿ $ ______________________ . . . . . . . . Total penalty 23
24 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 24
25 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 25
26 Are net direct premiums so reported in lines 1 and 3 of Part I?
Yes
No.
27 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.
28 If the answer to line 26 or line 27 is “No,” please explain ______________________________________________________________________________
Under the penalties of perjury, I declare that I have examined this return, including attachments, and to the best of my knowledge 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
❿
If you are signing as an authorized delegate of the appropriate corporate officer, check here
and attach Massachusetts Form M-2848, Power of Attorney.
Make check or money order payable to the Commonwealth of Massachusetts. Mail to: Mass. Department of Revenue, PO Box 7052, Boston, MA 02204.
Form Code 369 Tax Type 0119
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