IG260
2013 Nonadmitted Insurance Premium Tax Return for Surplus Lines Brokers
For the period of
Jan. 1 - June 30, 2013
July 1 - Dec. 31, 2013
(check one):
(Due Aug. 15, 2013)
(Due Feb. 15, 2014)
Check if:
Amended return
No activity
Name of surplus lines broker
License number
Date licensed
Agency name
Check if new address
Minnesota tax ID number—required (see instructions)
Mailing address
Social Security number (last 4 digits)
City
State
Zip code
Contact person
Email address
Website address
Daytime phone
Fax number
1 Total premiums (from page 2, column G) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Total fees and commissions (from page 2, column H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Total gross premiums (from page 2, column I) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Total return premiums (from page 2, column J). Enter as a positive number . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Taxable gross premiums (subtract line 4 from line 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
.03
6 Tax rate is 3% (.03) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Total tax (multiply line 5 by line 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 TOTAL AMOUNT DUE or (overpaid) (add lines 7 through 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
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 PV53)
Enter amount paid
Date paid
(If amount paid is different from amount due on line 10, attach an explanation.)
I declare that this return is correct and complete to the best of my knowledge and belief.
Signature of broker
Date
Daytime phone
I authorize the
Minnesota Department
of Revenue to discuss
Signature of preparer
Print name of preparer
Date
Daytime phone
this tax return with the
preparer.
Mail to: Minnesota Revenue, Mail Station 1780, St. Paul, MN 55145-1780
(Rev. 10/12)