Form 63-20-23 - Premium Excise Return For Foreign Life Insurance Companies On Life, Accident And Health Business - 2004

ADVERTISEMENT

Form 63-20-23
2004
Premium Excise Return for
Massachusetts
Foreign Life Insurance Companies on
Department of
Life, Accident and Health Business
Revenue
For calendar year 2004 or taxable year beginning
2004 and ending
Name of company
Federal Identification number
Mailing address
City/Town
State
Zip
Name of treasurer
Organized under the laws of
Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?
Yes
No
Computation of Excise.
Attach a copy of Schedule T of NAIC Annual Statement.
Income and Excise Before Credits
Use whole dollar method
❿ $ __________________ × .02 = ❿ 1
11 Taxable life premiums (from Premium Excise Calculation, line 7) . . . . . . . . . . . . . . . . . .
12 Retaliatory computation (from Computation of Retaliatory Tax, col. a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 2
13 Applicable measure (enter the larger of line 1 or line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
14 Taxable accident and health premiums (from Premium Excise Calculation, line 12). . . . ❿ $ __________________ × .02 = ❿ 4
15 Retaliatory computation (from Computation of Retaliatory Tax, col. b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5
16 Applicable measure. Enter the larger of line 4 or line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
17 Credit recapture (attach Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 7
18 Excise before credits. Add lines 3, 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Credits
19 Enter 1.5% of company’s capital contribution in excess of your full proportionate share in the Massachusetts life
insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 9
10 Enter 10% of Massachusetts Life and Health Insurance Guaranty Association assessment paid in the prior years. . . . . . . ❿ 10
11 Economic Opportunity Area Credit (attach Schedule EOAC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 11
12 Full Employment Credit (attach Schedule FEC). Do not claim here if claimed on Form 176-I . . . . . . . . . . . . . . . . . . . . . . . ❿ 12
13 Low-Income Housing Credit (enclose documentation). Do not claim here if claimed on Form 176-I . . . . . . . . . . . . . . . . . . ❿ 13
Excise After Credits
14 Excise due before voluntary contribution. Subtract the total of lines 9 through 13 from line 8. Not less than “0”. . . . . . . . . . . . 14
15 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15
16 Excise plus voluntary contribution. Add lines 14 and 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 16
Payments
17 2003 overpayment applied to 2004 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 17
18 2004 Massachusetts estimated tax payments. Do not include amount from line 17 . . . . . . . . . . ❿ 18
19 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 19
20 Total payments. Add lines 17 through 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Refund or Balance Due
21 Amount overpaid. Subtract line 16 from line 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Amount overpaid to be credited to 2005 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 22
23 Amount overpaid to be refunded. Subtract line 22 from line 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 23
24 Balance due. Subtract line 20 from line 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
25 M-2220 penalty ❿ $ ______________________ ; other penalties ❿ $ ______________________. . . . . . . . . Total penalty 25
26 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 26
27 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 27
Declaration
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
Individual or firm signature of preparer
Employee 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 remittance payable to: Commonwealth of Massachusetts. Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204.
Form Code 181 Tax Type 0120

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 4