Form Ct-33-D - Tax On Premiums Paid Or Payable To An Unauthorized Insurer

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CT-33-D
New York State Department of Taxation and Finance
Tax on Premiums Paid or Payable
(8/14)
To an Unauthorized Insurer
Amended
return
For Taxable Insurance Contracts with an Effective Date on
or after July 21, 2011
Tax Law — Article 33-A
Employer identification number (EIN) or social security number of insured
Insurance policy number
Name of insured
Calendar quarter and year policy effective /renewed
For Tax Department use only
Jan. - Mar.
Apr. - Jun.
(yyyy)
(yyyy)
Number and street or PO box
Jul. - Sep.
Oct. - Dec.
(yyyy)
(yyyy)
City
State
ZIP code
Telephone number
(
)
If the premiums paid are to an affiliated insurance company, provide the information requested below and mark an X in the box .....
Name of affiliated insurance company
EIN of affiliated insurance company
If premiums paid are an endorsement to the original policy, mark an X in the box
Effective date of endorsement:
Type of organization
(mark an X in one box)
Corporation
Partnership
Individual
Other:
A. Pay amount shown on line 8. Make payable to: Commissioner of Taxation and Finance.
Payment enclosed
Include on the payment your identification number, Form CT-33-D, and the calendar quarter
for which you are reporting.
A
(See instructions for details.)
Part 1 — Tax computation
1 Premiums paid or payable on taxable insurance contracts
..................................
1
(see instructions)
2 Tax rate of 3.6% ................................................................................................................................
2
0.036
3 Tax due
........................................................................................................
3
(multiply line 1 by line 2)
4 Prepayment .......................................................................................................................................
4
5 Balance
5
............................................................
(if line 3 is greater than line 4, subtract line 4 from line 3)
6 Interest on late payment
........................................................................................
6
(see instructions)
7 Penalties
................................................................................................................
7
(see instructions)
8 Total payment due
8
.........
(add lines 5, 6, and 7 and enter here; enter the payment amount on line A above)
9 Overpayment
9
Credit to next period
Refund
(if line 3 is less than line 4, subtract line 3 from line 4)
Part 2 — Insurer information
(attach additional sheets if necessary)
Name of insurance company
Number and street or PO box of insurance company
City
State
ZIP code
Certification: I certify that this return and any attachments are to the best of my knowledge and belief true, correct, and complete.
Printed name of authorized person
Signature of authorized person
Official title
Authorized
person
E-mail address of authorized person
Telephone number
Date
(
)
Firm’s name
Firm’s EIN
Preparer’s PTIN or SSN
Paid
(or yours if self-employed)
preparer
Signature of individual preparing this return
Address
City
State
ZIP code
use
only
E-mail address of individual preparing this return
Preparer’s NYTPRIN
Date
(see instr.)
See instructions for where to file.
475001140094

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