Form M11t - Insurance Premium Tax Return And Firetown Report For Township Mutual - 2014

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M11T
2014 Insurance Premium Tax Return and Firetown Report for
Township Mutual
Combined Report for Township Mutual Insurance Companies
Due March 1, 2015
Check if:
Amended Return
No Activity Return
Name of Insurance Company
FEIN
Minnesota Tax ID (required)
Mailing Address
NAIC Number
State/Country of Incorporation
Check if New Address
City
State
Zip Code
Contact Person
Daytime Phone
Email Address
Website Address
Fax Number
Date Licensed in Minnesota
1 Gross direct premiums, including policy fees, premium finance and other charges
(from annual statement filed with the Minnesota Department of Commerce; attach a copy) . . . . . . . . 1
1%
2 Premium tax percentage rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Premium tax liability (multiply line 1 by line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Credit for historic structure rehabilitation
(attach credit certificate) and enter NPS project number: . . . . . . . . . . . .
. . 4
5 Tax liability (subtract line 4 from line 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Premium tax prepayments
a Prior year‘s overpayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6a
b Estimated payment March 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6b
c Estimated payment June 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6c
d Estimated payment Sept. 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6d
e Estimated payment Dec. 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6e
Total payments (add lines 6a through 6e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Tax due (or overpaid) (subtract line 6 from line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 a Additional charge for underpaying estimated tax
(determine from worksheet in the instructions) . . . . . . . . . . . . . . . . . 8a
b Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8b
c Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8c
Total (add lines 8a through 8c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 TOTAL AMOUNT DUE (or overpaid) (add lines 7 and 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
If you owe additional tax:
Payment method:
Electronic payment
Check
(payable to Minnesota Revenue; write MN tax ID number on check; attach voucher)
Enter amount paid
Date paid
(If amount paid is different from amount due on line 9, attach an explanation.)
If you overpaid:
Amount on line 9 to be credited to next year‘s estimated tax . . . . . . . . . . . . .
Amount on line 9 to be refunded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I declare that this return is correct and complete to the best of my knowledge and belief.
Authorized Signature
Title
Date
Daytime Phone
I authorize the Minnesota
Department of Revenue to
discuss this tax return with
Signature of Preparer
Print Name of Preparer
Date
Daytime Phone
the preparer.
Mail to: Minnesota Revenue, Mail Station 1780, St. Paul, MN 55145-1780

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