Form 480.40f - Foreign Life Insurance Company Income Tax Return (Page 3 of 3) in pdf

Form 480.40F Rev. 02.17

Foreign Life Insurance Company - Page 3

Part V

Analysis of Home Office Account per Books

Balance at the beginning of the year ...................

Distributions:

(a)

Cash ....................................

(5a)

(1)

(b)

Property ...............................

(5b)

Net income per books ........................................

(2)

(c)

Stock ...................................

(5c)

Other increases (Itemize, use schedule if

Other decreases (Use schedule if necessary) _____________

necessary) _______________________________

_______________________________________________

____________________________________________

_______________________________________________

(6)

____________________________________________

Total (Add lines 5 and 6) .............................................

(7)

____________________________________________

(3)

Balance at end of year (Subtract line 7 from line 4)

(8)

Total (Add lines 1, 2 and 3) ..............................

(4)

Part VI

Questionnaire

Yes

Yes No

If a foreign corporation, indicate if the trade or business in Puerto Rico was

(9c)

held as a branch ...............................................................................

(1) Did more than 80% of the total income was derived from activities

(1)

If a branch, indicate the percent that represents the income from sources

exclusively related to fishing or transportation of passengers or

within Puerto Rico from the total income of the corporation: ________%

cargo or lease? ................................................................

(9c1)

Did the corporation keep any part of its accounting tax records on a computerized

(d) Residential property outside of Puerto Rico? ...................................

(9d)

system during this taxable year? ................................................................

(1) Did more than 80% of the total income was derived from activities

(3)

The corporation's books are in care of:

exclusively related to the lease of property to non related persons?

(9d1)

Name ________________________________________________________

Did the corporation claim expenses connected to:

10.

Address ______________________________________________________

(a) Housing (except business employees) .....................................

(10a)

E-mail ________________________________________________________

(b) Employees attending conventions or meetings outside Puerto Rico

Telephone _____________________________________________________

or the United States? ...............................................................

(10b)

Check method of accounting:

11.

Did the corporation distribute dividends other than stock dividends or

Cash

Accrual

distributions in liquidation in excess of the corporation's current and

Other (specify):_________________________________________

accumulated earnings? ..................................................................

(11)

Did the corporation file the following documents?:

12.

Is the corporation a partner in any special partnership? (If more than

(a) Informative Return (Forms 480.5, 480.6A, 480.6B) ...........................

one, submit detail) ..........................................................................

(12)

(6a)

(b) Withholding Statement (Form 499R-2/W-2PR) ..................................

Name of the special partnership _________________________________

(6b)

If the gross income exceeds $3,000,000, are financial statements audited by

Employer identification number _________________________________

a CPA licensed in Puerto Rico included with this return? ............................

13.

Did you receive exempt income? (Submit Schedule IE Corporation) ....

(7)

(13)

Number of employees during the year: ____________________________

14.

Enter the amount corresponding to qualified charitable contributions to

Did the corporation claim expenses related to the ownership, use, maintenance

municipalities : ________________________________________________

and depreciation of:

15.

Indicate if insurance premiums were paid to an unauthorized insurer ....

(15)

(a) Vehicles? ....................................................................................

Employer's number assigned by the Department of Labor and Human

16.

(9a)

(b) Vessels? .....................................................................................

Resources: _________________________________________________

(9b)

(1) Did more than 80% of the total income was derived from activities

17.

Number of stockholders: ______________________________________

exclusively related to fishing or transportation of passengers or

cargo or lease? ....................................................................

(9b1)

OATH

We, the undersigned, president (or vice president, or other principal officer) and treasurer (or assistant treasurer), or agent of the corporation for which

this income tax return is made, each for himself declare under penalty of perjury, that this return (including schedules and statements attached) has

been examined by us and is, to the best of our knowledge and belief, a true, correct, and complete return, made in good faith, pursuant to the Puerto

Rico Internal Revenue Code of 2011, as amended, and the Regulations thereunder.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_______________________________________

Treasurer's or assistant treasurer's signature

President's or vice president's signature

Agent

Specialist's Use Only

I declare under penalty of perjury that this return (including schedules and statements attached) has been examined by me, and to the best of my knowledge and

belief is a true, correct and complete return. The declaration of the person that prepares this return is with respect to the information received, and this information

may be verified.

Specialist's name (Print letter)

Registration number

Date

Specialist's social security number

Check if

self-employed

Firm's name

Employer's identification number

Specialist's signature

Address

Zip code