Form Ig261 - Fire Safety Surcharge Return - 2015

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IG261
2015 Fire Safety Surcharge Return
For the period of (check one):
Jan. 1 – March 31, 2015
April 1 – June 30, 2015
July 1 – Sept. 30, 2015
Oct. 1 – Dec. 31, 2015
(Due May 15)
(Due Aug . 15)
(Due Nov . 15)
(Due Feb . 15, 2016)
Check if:
Amended Return
No Activity Return
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 voucher)
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

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