Form 63-20p - Premium Excise Return For Life Insurance Companies - 2007

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2007
Form 63-20P
Massachusetts
Premium Excise Return
Department of
for Life Insurance Companies
Revenue
For calendar year 2007 or taxable year beginning
2007 and ending
Name of company
Federal Identification number
State of incorporation
3
3
Mailing address
City/Town
State
Zip
Name of treasurer
Applicable tax rate
.14
.12
.096
.072
.048
.024
3
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 I, 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 Massachusetts taxable investment income (from Sched. DL-2A, Part 3, line 9) 3 $ ________________ × applicable rate = 3 5
16 Credit recapture (enclose Schedule(s) H and/or H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6
17 Excise due before credits. Add lines 3 through 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Foreign Life Insurers.
Enclose a copy of Schedule T of NAIC Annual Statement.
18 Taxable life premiums (from Part 2, line 7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $_________________ × .02 = 3 8
19 Retaliatory computation (from Part 3, col. a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9
10 Applicable measure (enter the larger of line 8 or line 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Taxable accident and health premiums (from Part 2, line 12) . . . . . . . . . . . . . . . . . . . . . . . . 3 $________________ × .02 = 3 11
12 Retaliatory computation (from Part 3, col. b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 12
13 Applicable measure. Enter the larger of line 11 or line 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14 Credit recapture (enclose Schedule(s) H and/or H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 14
15 Excise due before credits. Add lines 10, 13 and 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Credits.
Do not claim any credit here if claimed on Form 63-23P.
16 Enter .015 of company’s capital contribution in excess of the full proportionate share in the Massachusetts life
insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 16
17 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) . . . . . . . . . . . . 3 17
18 Enter .10 of Mass. Life and Health Insurance Guaranty Association assessment paid in the prior years. See instructions 3 18
19 Domestic insurers only, credit if admitted assets reported on page 2 of Annual Statement are less than $240,000,000.
Enter $500 for each $1,000,000 that line 1 is below $240,000,000, up to a maximum of $20,000 (disregard fractions) . . . 3 19
20 Economic Opportunity Area Credit (enclose Schedule EOAC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 20
21 Full Employment Credit (enclose Schedule FEC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 21
22 Low-Income Housing Credit (enclose documentation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 22
23 Historic Rehabilitation Credit (enclose documentation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 23
24 Home Energy Efficiency Credit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 24
25 Solar Heat Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 25
26 Film Incentive Credit. Certificate number 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 26
27 Medical Device Credit. Certificate number 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 27
28 Brownfields Credit. Certificate number 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 28
29 Total credits. Add lines 16 through 28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
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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