Form 63-20-23 - Premium Excise Return For Foreign Life Insurance Companies On Life, Accident And Health Business - 1998

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Form 63-20-23

1998

Premium Excise Return for

Massachusetts

Foreign Life Insurance Companies on

Department of

Life, Accident and Health Business

Revenue

For calendar year 1998 or taxable year beginning

, 1998 and ending

, 19

Name of company

Federal Identification number

Mailing address

DOR Use Only

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

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

¨__________________$ × .02 (2%) = ¨1

11 Taxable life premiums (Part I, line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12 Retaliatory computation (Part II, column A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨2

13 Applicable measure (enter the larger of line 1 or line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Taxable accident and health premiums (Part I, line 12) . . . . . . . . . . . . . . . . . . . . . . ¨__________________$ × .02 (2%) = ¨4

15 Retaliatory computation (Part II, column B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨5

16 Applicable measure (enter the larger of line 4 or line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

17 Excise before credits.

Add line 3 and line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Credits

18 Enter 10% of Massachusetts 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 176-I,

do not claim it on this form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨9

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

Excise After Credits

11 Excise due before voluntary contribution. Subtract the total of lines 8, 9 and 10 from line 7. Not less than “0” . . . . . . . . . . . . . 11

12 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨12

13 Excise plus voluntary contribution. Add line 11 and line 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨13

Payments

14 1997 overpayment applied to 1998 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨14

15 1998 Massachusetts estimated tax payments (do not include amount from line 14) ¨15

16 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨16

17 Total payments. Add lines 14, 15 and 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Refund or Balance Due

18 Amount overpaid. Subtract line 13 from line 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

19 Amount overpaid to be credited to 1999 estimated tax . . . . . . . . . . . . . . . . . . . . . . . ¨19

20 Amount overpaid to be refunded. Subtract line 19 from line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨20

21 Balance due. Subtract line 17 from line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

22 M-2220 penalty ¨$ _______________________ ; Other penalties ¨ $ ______________________ . . . . . . . . Total penalty 22

23 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨23

24 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨24

25 Are net direct premiums so reported in Part I, line 8?

Yes

No.

26 Have all dividends claimed as a deduction in Part 1, line 9 been included as taxable premiums

in line 4 on this return or on a previous Massachusetts return?

Yes

No.

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 knowl-

edge 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

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.

Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204. Make remittance payable to: Commonwealth of Massachusetts.

Form Code 181 Tax Type 0120