Form It-95 - Informational Return Of Insurance Companies

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State of Rhode Island and Providence Plantations
Form IT-95
Informational Return of Insurance Companies
Decedent's first name
MI
Last name
Suffix
Decedent's social security number
Decedent's address - Legal residence (domicile) at time of death
City, town or post office
State
ZIP code
Insurance company information
Name:
Address:
Date of death
Type of contract
Name(s) of payee
Amount of proceeds if payable in
one sum
Value of proceeds if not paid in
one sum
Provisions of policy with respect
to the deferred payments or
installments
Owner of policy if not the insured
INSTRUCTIONS:
This form must be filed with the Rhode Island Division of Taxation within thirty (30) days of receipt of information
of the death of the insured where the payments made or to be made exceed fifity thousand ($50,000) dollars.
A SEPARATE STATEMENT MUST BE FILED FOR EACH INSURANCE CONTRACT
The undersigned officer of the above named insurance company hereby certifies that this statement is true and correct.
Auothorized signature
Print name
Date
Telephone number
Address
City, town or post office
State
ZIP Code
PTIN
Mail to RI Division of Taxation - One Capitol Hill - Providence, RI 02908
Revised 03/2016

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