IG261
2014 Fire Safety Surcharge Return
For the period of (check one):
Jan. 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – Sept. 30, 2014
Oct. 1 – Dec. 31, 2014
(Due May 15)
(Due Aug . 15)
(Due Nov . 15)
(Due Feb . 15, 2015)
Check if:
Amended return
No activity
Name of insurance company
FEIN
Minnesota tax ID (required)
Mailing address
Check if new address
NAIC number
State/country of incorporation
City
State
Zip code
Contact person
Email address
Website address
Daytime phone
Fax number
Note: Numbers in parentheses refer to line
A
B
C
numbers on NAIC Minnesota state page. Also
Direct Premiums
Dividends
Gross Premiums
include all finance and service charges.
(A minus B)
1 Homeowners policies (4) . . . . . . . . . . . . . . . . . . . . 1
2 Fire policies (1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Commercial nonliability policies (5.1) . . . . . . . . . . 3
4 Total (add lines 1 through 3) . . . . . . . . . . . . . . . . . 4
0.005
5 Surcharge rate (0.5%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Surcharge (multiply line 4c by the rate on line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 TOTAL AMOUNT DUE (or overpaid) (add lines 6 through 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
If you owe additional tax (make separate payments for each period):
Payment method:
Electronic payment
Check
(payable to Minnesota Revenue; write MN tax ID number on check; attach Form PV55)
Enter amount paid
Date paid
(If amount paid is different from amount due on line 9, attach an explanation.)
If you overpaid: Overpayments will 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
Signature of preparer
Print name of preparer
Date
Daytime phone
with the preparer .
Mail to: Minnesota Revenue, Mail Station 1780, St . Paul, MN 55145-1780