Form T-71a - Surplus Line Broker Return Of Gross Premiums - 2014

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State of Rhode Island and Providence Plantations
2014 Form T-71A
14111799990101
Surplus Line Broker Return of Gross Premiums
Name
Federal employer identification number/social security number
Address
State or country of incorporation or organization
Address 2
Broker license number
City, town or post office
State
ZIP code
E-mail address
Computation of Tax
1
Gross premium charged..........................................................................
1
2
Returned Premiums.................................................................................
2
3
Net Taxable Premium. Subtract line 2 from line 1.......................................................................................
3
Tax and
4
SURPLUS LINE BROKER TAX. Rate: 4%. Multiply line 3 by the tax rate of 4% (0.04)............................
4
Credits
5
Payments made on 2014 declaration of estimated tax ...........................
5
6
Net Tax Due. Subtract line 5 from line 4.....................................................................................................
6
Balance
Due
7
Interest Due: (a) Late payment
_____________
(b) Underestimating
__________
.................................
7
8
Total Due with Return. Add lines 6 and 7....................................................................................................
8
9
Overpayment. Subtract lines 4 and 7 from line 5.......................................................................................
9
Refund
10
Amount of overpayment to be applied to 2015 estimated tax..................................................................... 10
11
Amount to be refunded. Subtract line 10 from line 9.................................................................................. 11
INSURANCE AGENCIES:
ENTER THE FEDERAL IDENTIFICATION NUMBER OF THE AGENCY ONLY IN THE SPACE PROVIDED ABOVE. DO NOT ENTER A BROKER’S
SOCIAL SECURITY NUMBER. YOU MUST COMPLETE PAGE 2, LIST OF BROKERS, IN ORDER FOR THE INDIVIDUAL BROKER LICENSES TO
BE RENEWED. IF PAGE 2 IS NOT COMPLETED, LICENSE RENEWALS MAY BE DELAYED.
INDIVIDUALS:
YOU MUST ENTER YOUR SOCIAL SECURITY NUMBER IN THE SPACE PROVIDED ABOVE. DO NOT ENTER THE INSURANCE AGENCY’S
FEDERAL IDENTIFICATION NUMBER. SKIP PAGE 2, AND GO DIRECTLY TO PAGE 3.
Line 1:
Gross Premium Charged - From the Return Supplement on
Line 7:
Interest Due:
page 3, add the Premium Column Total to the Additional
(a) Late payment interest: 18% per annum, 1.5% per month.
Premium Column Total.
(b) Underestimating interest - see Regulation CT12-10.
Enter the sum of lines (a) and (b) on line 7.
Line 2:
Amount of Returned Premiums - From the Return Supplement
on page 3, enter the amount from Return Premium Column
Line 8:
Total Due with Return. Add lines 6 and 7.
Total.
Line 9:
Overpayment. Subtract lines 4 and 7 from line 5.
Line 3:
Net Taxable Premium. Subtract line 2 from line 1.
Line 10: Enter the amount from line 9 to be applied to 2015
Line 4:
Surplus Line Broker Tax. Multiply line 3 times rate of 4% (0.04).
Estimated Tax.
Line 5:
Enter the amount of estimated tax paid for tax year 2014, plus
Line 11: Subtract line 10 from line 9. This is the amount to be refunded.
any amounts applied from tax year 2012.
Mail Form T-71A by April 1, 2015 with any payment due to:
Line 6:
Net Tax Due. Subtract line 5 from line 4.
RI Division of Taxation - One Capitol Hill - Providence, RI 02908
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Authorized officer signature
Print name
Date
Telephone number
Paid preparer signature
Print name
Date
Telephone number
Paid preparer address
City, town or post office
State
ZIP code
PTIN
May the Division of Taxation contact your preparer? YES
Revised 09/2014
Key # 13

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