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2003

Form DL-2

Massachusetts

Investment Privilege Excise Return

Department of

for Domestic Life Insurance Companies

Revenue

For calendar year 2003 or taxable year beginning

2003 and ending

Name of company

Federal Identification number

❿

Principal business address

City/Town

State

Zip

Name of treasurer

Check applicable investment income tax rate: ❿

14%

12%

9.6%

7.2%

4.8%

2.4%

Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?

Yes

Computation of Excise.

Attach a copy of Schedule T of NAIC Annual Statement.

Income and excise before credits

Use whole dollar method

11 Admitted assets as of December 31, 2003 (from Annual Statement, pg. 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 1

12 Credit recapture (attach Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 2

× applicable rate ❿ 3

13 Massachusetts taxable investment income (from Schedule C, line 9) . . . . . . . . ❿ $ ________________

14 Excise before credits. Add lines 2 and 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Credits

15 Credit if line 1 is less than $240,000,000. Enter $500 for each $1,000,000 (disregard a fraction thereof) that line 1

is below $240,000,000, up to a maximum of $20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5

16 Economic Opportunity Area Credit (attach Schedule EOAC). Do not claim here if claimed on Form DL-1 or Form 176-I . . . ❿ 6

17 Full Employment Credit (attach Schedule FEC). Do not claim here if claimed on Form DL-1 or Form 176-I . . . . . . . . . . . . . ❿ 7

18 Low-Income Housing Credit (attach documentation). Do not claim here if claimed on Form DL-1 or Form 176-I . . . . . . . . . . ❿ 8

Excise after credits

19 Investment privilege excise due before voluntary contribution. Subtract total of lines 5 through 8 from line 4. Not less than “0” 9

10 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 10

11 Total excise plus voluntary contribution. Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 11

Payments

12 2002 overpayment applied to 2003 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 12

13 2003 Massachusetts estimated tax payments (do not include amount from line 12) . . . . . . . . . . ❿ 13

14 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 14

15 Total payments. Add lines 12 through 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Refund or balance due

16 Amount overpaid. Subtract line 11 from line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

17 Amount overpaid to be credited to 2004 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 17

18 Amount overpaid to be refunded. Subtract line 17 from line 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 18

19 Balance due. Subtract line 15 from line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

20 M-2220 penalty ❿!$_______________________ ; Other penalties ❿________________________ . . . . . . . . Total penalty 20

21 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 21

22 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 22

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

Signature of paid preparer

Employer Identification number

Address

Date

❿

If you are signing as an authorized delegate of the appropriate corporate officer,