Form 63-20p - Premium Excise Return For Life Insurance Companies - 2012

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2012
Form 63-20P
Massachusetts
Premium Excise Return
Department of
for Life Insurance Companies
Revenue
For calendar year 2012 or taxable year beginning
2012 and ending
Name of company
Federal Identification number
State of incorporation
3
3
Mailing address
City/Town
State
Zip
Name of treasurer
Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?
Yes
No
Excise Calculation
Domestic Life Insurers.
Enclose a copy of Schedule T of NAIC Annual Statement.
11 Taxable life premiums (from Part 1, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $_________________ × .02 = 3 1
12 Net value of policies (from Schedule DL-1A, Part II, line 12). . . . . . . . . . . . . . . . . . . . . . . . 3 $_______________ × .0025 = 3 2
13 Applicable measure (from line 1 or line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3
14 Taxable accident and health premiums (from Part 1, line 11). . . . . . . . . . . . . . . . . . . . . . . 3 $_________________ × .02 = 3 4
15 Credit recapture (enclose Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5
16 Excise due before credits. Add lines 3 through 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6
Foreign Life Insurers.
Enclose a copy of Schedule T of NAIC Annual Statement.
17 Taxable life premiums (from Part 2, line 7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $_________________ × .02 = 3 7
18 Retaliatory computation (from Part 3, col. a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 8
19 Applicable measure (enter the larger of line 7 or line 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Taxable accident and health premiums (from Part 2, line 12) . . . . . . . . . . . . . . . . . . . . . . . . 3 $________________ × .02 = 3 10
11 Retaliatory computation (from Part 3, col. b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 11
12 Applicable measure (enter the larger of line 10 or line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Credit recapture (enclose Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 13
14 Excise due before credits. Add lines 9, 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 14
Credits.
Do not claim any credit here if claimed on Form 63-23P.
15 Enter 1.5% of company’s capital contribution in excess of the full proportionate share in the Massachusetts life
insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 15
16 Enter 1.5% of proportionate share of cost of equity securities and outstanding principal balance of debt securities
constituting of qualified investments of Massachusetts Capital Resource Company (enclose computation) . . . . . . . . . . . . 3 16
17 Enter 10% of Mass. Life and Health Insurance Guaranty Association assessment paid in the prior years (see instr.) . . . . . 3 17
18 Economic Opportunity Area Credit (enclose Schedule EOAC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 18
19 Economic Development Incentive Program Credit. Certificate number 3
. . . . . . . . . . . . . . . . . . 3 19
20 Low-Income Housing Credit. Building Identification number 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 20
21 Historic Rehabilitation Credit. Certificate number 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 21
22 Film Incentive Credit. Certificate number 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 22
23 Medical Device Credit. Certificate number 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 23
24 Brownfields Credit. Certificate number 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 24
25 Life Science Company Investment Tax Credit under section 38U. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 25
26 Life Science Company FDA User Fee Credit under section 31M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 26
27 Life Science Company Research and Development Credit under section 38W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 27
28 Total credits. Add lines 15 through 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Under penalties of perjury, I declare that to the best of my knowledge and belief, this return and enclosures are true, correct and complete.
Signature of appropriate corporate officer (see instructions)
Social Security number
Telephone number
Date
Signature of paid preparer
Employer Identification number
Address
Date
If you are signing as an authorized delegate of the appropriate corporate officer,
check here and attach Mass. Form M-2848, Power of Attorney. The Privacy
Act Notice is available upon request. Make check or money order payable to: Commonwealth of Massachusetts. Mail to: Massachusetts Department
of Revenue, PO Box 7052, Boston, MA 02204.
Form code 387 / Tax type 0120

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