Tax Disclosure Report Foreign Property And Casualty Insurance Companies Form - The Commonwealth Of Massachusetts Page 2

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In these instructions, all references to Massachusetts tax forms refer to 2013 forms. If you are using forms for any other year when supplying informa-

tion, be sure that you include the substantive information required by statute. Forms for other years may be numbered differently.

INSTRUCTIONS FOR COMPLETION OF THIS FORM

Note: The information for this filing must come from your most recently filed tax return or other document filed on or before June 30, 2015.

Please type or print clearly in ink as this document will be microfilmed. Incomplete or incorrect reports will be returned to sender for completion and/or correction.

Please send original document only; keep a photocopy for your files.

A. Insert Federal Identification Number (employer’s I.D.) at upper right-hand corner. If you do not have one, you must apply to the Internal Revenue Service.

B. Item 1. Insert the exact name of the insurance company as it appears on the Articles of Organization or subsequent amendments. Do not use any d/b/a names, trade

names, or abbreviations.

C. Item 2. Insert the full address of the insurance company’s principal office, using number and street, city or town, state and zip code.

D. Complete the statement by inserting the name of the treasurer/assistant treasurer completing this form. Date and sign where indicated, and insert title. The officer who

prepares this report must be the one who signs it. In the absence of the treasurer/assistant treasurer, the report may be signed by the president, vice-president, or clerk.

E. Item 3. Insert the last day, month and year of the tax year for which the report is filed.

F. Item 4. Insert the gross receipts or sales as reported on the company’s National Association of Insurance Commissioners Annual Statement, determined by adding the

amounts reported in Columns 2 and 8 of Line 99 of Schedule T of said Annual Statement and the amounts reported on the Underwriting and Investment Exhibit State-

ment of Income on Line 13 of page 4 of said Annual Statement.

G. Item 5. Insert the premiums taxable in Massachusetts as reported on Item 10 of Form 63-23P.

H. Item 6. Insert the total Massachusetts excise or tax due as reported on Item 35 of Form 63-23P.

I. Item 7. Insert the amount of each tax credit taken against the excise imposed by Massachusetts General Laws, Chaper 63 as reported on Form 63-23P.

tdrfpcic 12/18/15