Form 480.40f - Foreign Life Insurance Company Income Tax Return
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1
2
3Form 480.40F Rev. 02.17
Reviewer:
Liquidator:
Serial Number
______
GOVERNMENT OF PUERTO RICO
______
DEPARTMENT OF THE TREASURY
Year
Year
Field audited by:
Foreign Life Insurance Company
AMENDED RETURN
Income Tax Return
TAXABLE YEAR:
Date ___/ ___/ ___
1
CALENDAR 2
FISCAL 3
52-53 WEEKS
R
M
N
TAXABLE YEAR BEGINNING ON
Payment Stamp
_________
__
__________
___
, __
AND ENDING ON
, __
Employer's Identification Number
Taxpayer's Name
Postal Address
Department of State Registry No.
Industrial Code
Municipal Code
Zip Code
Merchant's Registration Number
Location of Principal Industry or Business - Number, Street, City
Telephone Number - Extension
Date Incorporated
Check the corresponding box, if applicable
Change of Address
FOR COLLECTOR'S USE ONLY
First return
Last return
Day___/ Month____/ Year____
Receipt Control Number
Yes
No
Place Incorporated
Contracts with Governmental Entities
No. _____________________________________
Yes
No
Amount: ________________________________
Part I
Net Income
1. Life insurance company taxable income (As reported on attached certified copy of income tax return
filed with the U.S. Commissioner of lnternal Revenue or foreign country) .....................................................................................................
(1)
00
2. Puerto Rico gross direct business (As reported on Schedule T in the Annual Statement required under
Section 3.310 of the Puerto Rico Insurance Code):
00
(2a)
a) Puerto Rico gross direct life insurance premiums .................................................................................
00
(2b)
b) Puerto Rico gross direct annuity considerations ...................................................................................
00
(2c)
c) Puerto Rico gross direct accident and health insurance premiums ..........................................................
00
(2d)
d) Puerto Rico gross direct annuity and other fund deposits .......................................................................
3. Total Puerto Rico gross direct business (Add lines 2(a) through 2(d)) ............................................................................................................
(3)
00
4. Total direct business (As reported on Schedule T in the Annual Statement required under Section 3.310
of the Puerto Rico Insurance Code):
00
a) Total direct business on life insurance premiums .................................................................................
(4a)
00
b) Total direct business on annuity considerations ....................................................................................
(4b)
00
c) Total direct business on accident and health insurance premiums ..........................................................
(4c)
00
d) Total direct business on annuity and other fund deposits ........................................................................
(4d)
5. Total direct business (Add lines 4(a) through 4(d)) ......................................................................................................................................
(5)
00
6. Allocation factor (Divide line 3 by line 5) ...................................................................................................................................................
(6)
7. Net income subject to normal tax (Multiply line 1 by line 6) ...................................................................................................................
(7)
00
8. Less: Surtax net income credit (See instructions) ......................................................................................................................................
(8)
00
9. Net income subject to surtax (Subtract line 8 from line 7) ........................................................................................................................
(9)
00
Part II
Computation of Tax
10.
Normal tax (Multiply line 7 by 20%) .....................................................................................................................................................
00
(10)
11.
Surtax (See instructions) .....................................................................................................................................................................
00
(11)
12.
Total tax (Add lines 10 and 11) ............................................................................................................................................................
00
(12)
13.
Alternative Tax - Capital Gains and Preferential Rates (Schedule D1 Corporation, line 9) ...........................................................................................
00
(13)
14.
Tax Determined (Line 12 or 13, whichever is smaller, provided that line 13 is more than zero) .................................................................................
00
(14)
15.
00
Recapture of investment credit claimed in excess (Schedule B Corporation, Part I, line 3) ............................................................................
(15)
16.
Tax credits (Schedule B Corporation, Part II, line 26) ..............................................................................................................................
00
(16)
17.
Tax liability before alternative minimum tax (Subtract line 16 from the sum of lines 14 and 15) ..............................................................
00
(17)
00
18.
Alternative minimum tax (Schedule A Corporation, Part V, line 33) ............................................................................................................
(18)
19.
Branch profits tax (Form AS 2879, line 11) .............................................................................................................................................
00
(19)
20.
Deemed dividend tax (See instructions) (Form AS 2877, Deemed Dividend Tax, Part III line 13) (See instructions) .........................................
00
(20)
21.
Total Tax Liability (Add lines 17 through 20) ........................................................................................................................................
00
(21)
22.
Less: Other Payments and Withholdings (Schedule B Corporation, Part III, line 11) ..............................................................................
00
(22)
23.
Balance of tax due (If line 21 is larger than line 22, enter the difference here,
otherwise, on line 25)
(a)
Tax ..................................................................................................
00
(23a)
(b)
00
Interest .............................................................................................
(23b)
00
(c)
Surcharges .......................................................................................
(23c)
(d)
Total (Add lines 23(a) through 23(c)) ...........................................................................................
00
(23d)
24.
Amount paid with this return ...............................................................................................................................................................
00
(24)
25.
Amount overpaid (If line 21 is smaller than line 22, distribute the difference between line A or B)
A. To be credited to estimated tax for (Year)__________ ..................................................................................................................
00
(25A)
B. To be refunded ......................................................................................................................................................................
00
(25B)
Retention Period: Ten (10) years
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