Form Dl-1 - Premium Excise Return For Domestic Life Insurance Companies

1999

Form DL-1

Massachusetts

Premium Excise Return

Department of

for Domestic Life Insurance Companies

Revenue

For calendar year 1999 or taxable year beginning

, 1999 and ending

Name of company

Federal Identification number

Mailing address

DOR use only

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.

If “Yes,” report such change on Form 355FC within three months after the final federal determination.

Computation of Excise.

Attach a copy of Schedule T of NAIC Annual Statement.

Income and Excise Before Credits

Use whole dollar method

11 Taxable life premiums (Part I, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ $ ________________ at 2% = . . . . . . . ¨1

12 Net value of policies (Part II, line 12 of Schedule DL-1A). . . . . . . . . . . . . . . . . . ¨ $ ________________ at .25% = . . . . . . ¨2

13 Applicable measure (line 1 or line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨3

14 Taxable accident and health premiums (Part I, line 11) . . . . . . . . . . . . . . . . . . . ¨ $ ________________ at 2% = . . . . . . . ¨4

Add lines 3 and 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

15 Total excise due before credits.

Credits

16 Enter 1.5% of company’s capital contribution in excess of your full proportionate share in the Massachusetts life

insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨6

17 Enter 1.5% of proportionate share of cost of equity securities and outstanding principal balance of debt

securities constituting qualified investments of Massachusetts Capital Resource Company (attach computation) . . . . . . . . . ¨7

18 Enter 10% of Mass. Life and Health Insurance Guaranty Association assessment paid in the prior years (see instructions) ¨8

19 Economic Opportunity Area Credit (Schedule EOA, line 9). If this credit was claimed on Form DL-2

or Form 176-I, do not claim it on this form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨9

10 Full Employment Credit (Schedule FEC). If this credit was claimed on form DL-2 or Form 176-I, do not claim it here . . . . . ¨10

11 Total credits. Add lines 6, 7, 8, 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Excise After Credits

12 Excise due before voluntary contribution. Subtract line 11 from line 5. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

13 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨13

14 Total excise plus voluntary contribution. Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨14

Payments

15 1998 overpayment applied to 1999 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨15

16 1999 Massachusetts estimated tax payments (do not include amount from line 15) ¨16

17 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨17

18 Total payments. Add lines 15, 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Refund or Balance Due

19 Amount overpaid. Subtract line 14 from line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

20 Amount overpaid to be credited to 2000 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . ¨20

21 Amount overpaid to be refunded. Subtract line 20 from line 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨21

22 Balance due. Subtract line 18 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

23 M-2220 penalty ¨ $ ______________________ ; Other penalties ¨ $ ______________________ . . . . . . . . Total penalty 23

24 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨24

25 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨25

Declaration

Under the penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, 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

Title

Date

Individual or firm signature of preparer

Employer Identification number

Address

Date