Form 63-20p - Premium Excise Return For Life Insurance Companies - 2005

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2005
Form 63-20P
Massachusetts
Premium Excise Return
Department of
for Life Insurance Companies
Revenue
For calendar year 2005 or taxable year beginning
2005 and ending
Name of company
Federal Identification number
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
Premium Excise
Domestic Life Insurers.
Enclose a copy of Schedule T of NAIC Annual Statement.
11 Taxable life premiums (from Part I, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ $ ________________ × .02 = ‹ 1
12 Net value of policies (from Schedule DL-1A, Part II, line 12) . . . . . . . . . . . . . . . . . . . . . . . . ‹ $ ______________ × .0025 = ‹ 2
13 Applicable measure (from line 1 or line 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 3
14 Taxable accident and health premiums (from Part I, line 11) . . . . . . . . . . . . . . . . . . . . . . . ‹ $ ________________ × .02 = ‹ 4
15 Credit Recapture (enclose Schedule H-2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 5
16 Excise due before credits. Add lines 3 through 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Foreign Life Insurers.
Enclose a copy of Schedule T of NAIC Annual Statement.
17 Taxable life premiums (from Part 2, line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ $ ________________ × .02 = ‹ 7
18 Retaliatory computation (from Part 3, col. a). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 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) . . . . . . . . . . . . . . . . . . . . . . . . ‹ $ _______________ × .02 = ‹ 10
11 Retaliatory computation (from Part 3, col. b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 11
12 Applicable measure. Enter the larger of line 10 or line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Credit recapture (enclose Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 13
14 Excise due before credits. Add lines 9, 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Credits
15 Enter .015 of company’s capital contribution in excess of the full proportionate share in the Massachusetts life
insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 15
16 Enter .015 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) . . . . . . . . . . . . . ‹ 16
17 Enter .10 of Mass. Life and Health Insurance Guaranty Association assessment paid in the prior years. See instructions ‹ 17
18 Economic Opportunity Area Credit (enclose Schedule EOAC). Do not claim here if claimed on Form 63-23P . . . . . . . . . . . ‹ 18
19 Full Employment Credit (enclose Schedule FEC). Do not claim here if claimed on Form 63-23P . . . . . . . . . . . . . . . . . . . . . ‹ 19
20 Low-Income Housing Credit (enclose documentation). Do not claim here if claimed on Form 63-23P . . . . . . . . . . . . . . . . . ‹ 20
21 Historic Rehabilitation Credit (enclose documentation). Do not claim here if claimed on Form 63-23P . . . . . . . . . . . . . . . . . ‹ 21
22 Home Energy Efficiency Credit. Do not claim here if claimed on Form 63-23P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 22
23 Solar Heat Credit. Do not claim here if claimed on Form 63-23P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 23
24 Total credits. Add lines 15 through 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Excise after credits
25 Excise due before voluntary contribution. Subtract line 24 from line 6 or line 14, whichever applies. Not less than “0” . . . . . . 25
26 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 26
27 Total excise plus voluntary contribution. Add lines 25 and 26 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 27
Under the penalties of perjury, I declare that I have examined this return, including attachments, and to the best of my knowledge and belief, it is
true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has knowledge.
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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