Form 63-20-23 - Premium Excise Return For Foreign Life Insurance Companies On Life, Accident And Health Business - 2000

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Form 63-20-23

2000

Premium Excise Return for

Massachusetts

Foreign Life Insurance Companies on

Department of

Life, Accident and Health Business

Revenue

For calendar year 2000 or taxable year beginning

2000 and ending

Name of company

Federal Identification number

❿

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

No.

If “Yes,” report such change on Form CA-6, Application for Abatement/Amended Return, 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

❿ $ ________________ × .02 (2%) =

❿ 1

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

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

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

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

❿ 4

15 Retaliatory computation (Part II, column B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 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 1.5% of company’s capital contribution in excess of your full proportionate share in the Massachusetts life

insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 8

19 Enter 10% of Massachusetts Life and Health Insurance Guaranty Association assessment paid in the prior years . . . . . . . . ❿ 9

10 Economic Opportunity Area Credit (Schedule EOA, line 9). If this credit was claimed on Form 176-I, do not claim here . . . ❿ 10

11 Full Employment Credit (Schedule FEC). If this credit was claimed on Form 176-I, do not claim it on this form . . . . . . . . . ❿ 11

Excise After Credits

12 Excise due before voluntary contribution. Subtract the total of lines 8, 9, 10 and 11 from line 7. Not less than “0” . . . . . . . . . . 12

13 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 13

14 Excise plus voluntary contribution. Add line 12 and line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 14

Payments

15 1999 overpayment applied to 2000 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15

16 2000 Massachusetts estimated tax payments (do not include amount from line 15) ❿ 16

17 Payments made with extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 17

18 Total payments. Add lines 15, 16 and 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Refund or Balance Due

19 Amount overpaid. Subtract line 14 from line 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

20 Amount overpaid to be credited to 2001 estimated tax . . . . . . . . . . . . . . . . . . . . . . . ❿ 20

21 Amount overpaid to be refunded. Subtract line 20 from line 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 21

22 Balance due. Subtract line 18 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

23 M-2220 penalty ❿ $ ______________________ ; other penalties ❿ $ ______________________. . . . . . . . . Total penalty 23

24 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 24

25 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 25

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

Yes

No.

27 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

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)