Form Ig257 - Firefighter Relief Surcharge Return - 2012-2013

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IG257

2012–2013 Firefighter Relief Surcharge Return

For the period of (check one):

Nov 1, 2012 – March 31, 2013

April 1, 2013 – May 31, 2013

June 1, 2013 – Oct. 31, 2013

(Due April 30)

(Due June 30)

(Due Nov. 30)

Check if:

Amended return

No activity

Name of insurance company

FEIN

Minnesota tax ID (required)

Mailing address

Check if new address

NAIC number

State/country of incorporation

City

State

Zip code

Contact person

Email address

Website address

Daytime phone

Fax number

Rochester

Duluth

St. Paul

Minneapolis

1 Gross fire, lightning and sprinkler-

leakage premiums written (include

finance, service and other charges) . . . . 1

2 Premiums returned to insured,

including dividends . . . . . . . . . . . . . . . . . 2

3 Net fire, lightning and sprinkler-leakage

premiums (subtract line 2 from line 1) . 3

4 Surcharge by city

(multiply line 3 by 2% [.02]) . . . . . . . . . . . 4

5 Total surcharge due (or overpaid) (add amounts on line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

8 TOTAL AMOUNT DUE (or overpaid) (add lines 5 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

If you owe additional tax (make separate payments for each period):

Payment method:

Electronic payment

Check

(payable to Minnesota Revenue; write MN tax ID number on check; attach PV51)

Enter amount paid

Date paid

(If amount paid is different from amount due on line 8, attach an explanation.)

If you overpaid: Overpayments will be refunded.

I declare that this return is correct and complete to the best of my knowledge and belief.

Authorized signature