Form It-95 - Informational Return Of Insurance Companies printable pdf download

Form It-95 - Informational Return Of Insurance Companies

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

DEPARTMENT OF REVENUE

DIVISION OF TAXATION

ONE CAPITOL HILL

PROVIDENCE, RI 02908

ESTATE TAX SECTION

INFORMATIONAL RETURN OF INSURANCE COMPANIES

Insurance Company Information

Name:

Address:

Name:

Insured or Annuitant Information

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 FIFTY THOUSAND ($50,000) DOLLARS.

A SEPARATE STATEMENT MUST BE FILED FOR EACH INSURANCE CONTRACT

The undersigned officer of the above name insurance company hereby certifies that this statement is true and correct.

SIGNATURE

TITLE

DATE

IT-95

Revised

12/18/2009

Form It-95 - Informational Return Of Insurance Companies