Fillable Form M19 - Insurance Premium Estimated Tax Payment printable pdf download

Insurance Premium Estimated Tax Payment

M19

IMPORTANT:

Type in the required information while this form is on the screen and print a copy. A personalized scan

line will be printed on the voucher using the information you entered. To help ensure your payment is properly credited

to your account, verify that the period end date and Minnesota tax ID number are included in the scan line.

When you print this voucher, be sure to set the Page Scaling to “None” in your Print options. DO NOT check the “Auto-

rotate and center pages” or “Shrink to fit” boxes. If they are already checked, click on the box to uncheck them.

Pay Electronically

Pay by Credit or Debit Card

Before a Payment Can Be

• Go to and log

• Go to payMNtax.com; or

Made

in to e-Services; or

• Call 1‑855‑9‑IPAY‑MN.

To ensure your payment is processed cor-

• Call 1‑800‑570‑3329 to pay by phone.

rectly, you must have a Minnesota tax ID

You will be charged a fee to use this service,

number. To register for a Minnesota tax ID

which goes directly to Value Payment

You’ll need your username, password

number:

Systems (a national company that partners

and banking information. When paying

with federal, state and local governments to

electronically, you must use an account not

• Go to and

provide credit/debit card payment services).

associated with any foreign banks.

click “Register for a Minnesota tax ID

number” on the e-Services menu; or

After you authorize the payment, you’ll re-

The Department of Revenue does not have

• Register by phone at 651‑282‑5225 or

ceive a confirmation number. You can can-

any financial agreement with Value Payment

Systems and does not receive any of its fees.

1‑800‑657‑3605.

cel a payment up to one business day before

the scheduled payment date, if needed.

Pay by Check

Do not send in the voucher below unless

If you are not required to pay electroni-

you are paying by check.

cally, you may pay by check. Complete the

voucher below and mail it with your check.

All information is required to process your

payment, including your Minnesota tax ID

number.

When you pay by check, your check autho-

rizes us to make a one-time electronic fund

transfer from your account, and you may

not receive your cancelled check.

Cut carefully along this line to detach.

M19

076

Insurance Premium Estimated Tax Payment

Minnesota Tax ID

(required)

Name of insurance company

Mailing address

NAIC Number

Enter the last day of the period. Use

City

State

ZIP code

mmddyy format.

Period End Date

Example: If making a 2013 estimated

(mmddyy)

Name of contact person

Phone

tax payment, enter 123113 for all four

quarters.

Make check payable to Minnesota Revenue and mail to:

AMOUNT

Minnesota Revenue, Mail Station 1785, St. Paul, MN 55145-1785

OF CHECK

To help ensure your payment is properly credited to your account, be sure to verify that the scan line below includes the correct period end date and your Minnesota tax ID.

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Form M19 - Insurance Premium Estimated Tax Payment

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