Form Pv52 - Hmo Insurance Premium Tax Return Payment

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HMO Insurance Premium Tax Return Payment

PV52

(M11H filers)

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 You Can Make a

• Go to and log

• Go to payMNtax.com; or

Payment

in to e‑Services; or

• Call 1‑855‑9‑IPAY‑MN.

To ensure your payment is processed

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

correctly, 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

You’ll need your Minnesota tax ID number,

which goes directly to Value Payment

number:

password and banking information. When

Systems (a national company that partners

• Go to ; or

paying electronically, you must use an ac‑

with federal, state and local governments to

count not associated with any foreign banks.

provide credit/debit card payment services).

• Register by phone at 651‑282‑5225 or

1‑800‑657‑3605.

After you authorize the payment, you’ll re‑

The Department of Revenue does not have

ceive a confirmation number. You can can‑

any financial agreement with Value Payment

cel a payment up to one business day before

Systems and does not receive any of its fees.

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.

PV52

504

HMO Insurance Premium Tax Return

Payment

Minnesota Tax ID

(required)

Name of insurance company

Mailing address

NAIC Number

City

State

ZIP code

Enter the last day of your tax year.

Period End Date

Use mmddyy format. Example: If your

(mmddyy)

tax year ends 12/31/13, enter 123113.

AMOUNT

Make check payable to Minnesota Revenue and mail with Form M11H.

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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