Form T-71h - Health Insurance Companies Tax Return Of Gross Premiums - 2009

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Form T-71H
State of Rhode Island and Providence Plantations
HEALTH
HEALTH INSURANCE COMPANIES TAX RETURN OF GROSS PREMIUMS
INSURANCE
for Calendar Year Ending December 31, 2008
2009
Due on or before March 1, 2009
NAME
ADDRESS
CITY
STATE
ZIP CODE
FEDERAL IDENTIFICATION NUMBER
.
STATE OR COUNTRY OF INCORPORATION OR ORGANIZATION
COMPANY TYPE:
.
THIS FORM IS TO BE USED BY NONPROFIT HOSPITAL SERVICE CORPORATIONS, NONPROFIT MEDICAL SERVICE
CORPORATIONS AND HEALTH MAINTENANCE ORGANIZATIONS
NOTE ATTACH LEGIBLE COPY OF SCHEDULE T AND SCHEDULE OF DIRECT BUSINESS IN THIS STATE FROM THE
ANNUAL STATEMENT SUBMITTED TO THE INSURANCE COMMISSIONER
Tax Computation
Tax and Fee
Direct Premiums (Gross less return premiums from Schedule T, Part 1 of Annual Statement to Insurance
.
.
1
1
Commissioner) .................................................................................................................................................................
Amount
.
TAX - 1.1% (0.011) of Line 1............................................................................................................................................
2.
2
Credits and
.
.
RI Credits: Form #__________ $________ Form #__________ $__________ Form #__________ $____________
3
3
Payments
4.
TAX AFTER CREDITS - LINE 2 LESS LINE 3 ...............................................................................................................
4.
5.
a. Payments made on 2008 Declaration of Estimated Tax ....................................................
5.
6.
b. Other Payments .................................................................................................................
4.
6.
7.
TOTAL PAYMENTS - Add lines 5 and 6 ..........................................................................................................................
7.
Balance Due
8.
Net Tax Due - Line 4 minus Line 7 .................................................................................................................................
8.
9.
Interest Due - 18% per annum (1.5% per month) ...........................................................................................................
9.
10.
Total due with return - Add lines 8 and 9 ........................................................................................................................
10.
Refund
11.
Overpayment - Line 7 minus Line 4 ................................................................................................................................
11.
12.
Amount of overpayment to be applied to Estimated Tax for 2009 Calendar Year ..........................................................
12.
13.
Amount to be refunded - Line 11 minus Line 12 ............................................................................................................
13.
CERTIFICATION: This certification must be executed or the return must be sworn before some person authorized to administer oaths.
Under penalties of perjury, I hereby certify that I have personal knowledge of the statements and other information constituting this return, that the same are true, correct
and complete to the best of my knowledge and belief.
Date
Signature of authorized officer
Title
Date
Signature of preparer
Address of preparer
MAY THE DIVISION CONTACT YOUR PREPARER ABOUT THIS RETURN? YES
NO
Phone number
MAILING ADDRESS: RHODE ISLAND DIVISION OF TAXATION, ONE CAPITOL HILL, PROVIDENCE, RI 02908-5811
key 13

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