Form Dl-1 - Premium Excise Return For Domestic Life Insurance Companies - 2004

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2004
Form DL-1
Massachusetts
Premium Excise Return
Department of
for Domestic Life Insurance Companies
Revenue
For calendar year 2004 or taxable year beginning
2004 and ending
Name of company
Federal Identification number
Mailing address
City/Town
State
Zip
Name of treasurer
Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?
Yes
No
Computation of Excise.
Attach a copy of Schedule T of NAIC Annual Statement.
Use whole dollar method
× 2% = ❿ 1
11 Taxable life premiums (from Part I, line 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ $ ________________
12 Net value of policies (from Schedule DL-1A, Part II, line 12) . . . . . . . . . . . . . . . . . . . . . ❿ $ ________________ × .25% = ❿ 2
13 Applicable measure (from line 1 or line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 3
14 Taxable accident and health premiums (from Part I, line 11). . . . . . . . . . . . . . . . . . . . . . . ❿ $ ________________ × 2% = ❿ 4
15 Credit recapture (attach Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5
16 Total excise due before credits. Add lines 3 through 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Credits
17 Enter 1.5% of company’s capital contribution in excess of the full proportionate share in the Massachusetts life
insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 7
18 Enter 1.5% of proportionate share of cost of equity securities and outstanding principal balance of debt securities
constituting of qualified investments of Massachusetts Capital Resource Company (attach computation) . . . . . . . . . . . . . . . ❿ 8
19 Enter 10% of Mass. Life and Health Insurance Guaranty Association assessment paid in the prior years. See instructions ❿ 9
10 Economic Opportunity Area Credit (attach Schedule EOAC). Do not claim here if claimed on Form 176-I . . . . . . . . . . . . . ❿ 10
11 Full Employment Credit (attach Schedule FEC). Do not claim here if claimed on Form 176-I . . . . . . . . . . . . . . . . . . . . . . . ❿ 11
12 Low-Income Housing Credit (attach documentation). Do not claim here if claimed on Form 176-I . . . . . . . . . . . . . . . . . . . . ❿ 12
13 Total credits. Add lines 7 through 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Excise after credits
14 Excise due before voluntary contribution. Subtract line 13 from line 6. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15
16 Total excise plus voluntary contribution. Add lines 14 and 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 16
Payments
17 2003 overpayment applied to 2004 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 17
18 2004 Massachusetts estimated tax payments (do not include amount from line 17). . . . . . . . . . ❿ 18
19 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 19
20 Total payments. Add lines 17 through 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Refund or balance due
21 Amount overpaid. Subtract line 16 from line 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Amount overpaid to be credited to 2005 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 22
23 Amount overpaid to be refunded. Subtract line 22 from line 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 23
24 Balance due. Subtract line 20 from line 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
25 M-2220 penalty ❿ $ ______________________ ; Other penalties ❿ $ ______________________ . . . . . . . . Total penalty 25
26 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 26
27 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 27
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
If you are signing as an authorized delegate of the appropriate corporate officer,
check here and attach Mass. Form M-2848, Power of Attorney.
The Privacy Act Notice is available upon request. Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204. Make check or
money order payable to: Commonwealth of Massachusetts.
Form Code 365 Tax Type 0123

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