Form T-69es-Slb - Declaration Of Surplus Lines Broker Estimated Tax - 2013
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1
2DECLARATION OF SURPLUS LINES BROKER - ESTIMATED TAX VOUCHER INSTRUCTIONS
1. Every surplus lines broker liable for the gross premiums tax shall file a declaration of its estimated tax for the calendar
year if its estimated tax for such taxable year can reasonably be expected to exceed $500.00. The entire amount of such
estimated tax shall constitute the amount of advance required to be paid.
2. The amounts and due dates of the installments are as follows:
--> 25% of the calendar year tax by April 30th
--> 50% of the calendar year tax by June 30th
--> 75% of the calendar year tax by October 31st
--> 100% of the calendar year tax by December 31st
3. Every surplus lines broker is subject to an assessment of 18% per annum for underpayments and penalties for the
willful neglect or failure to file a declaration or pay any installment due thereunder.
4. When there is not an increase in the tax rate from one year to the next, no interest or penalty will occur for underestimated
tax payment, if prepayments are made equal to the prior year’s tax.
5. Mail voucher and payment to:
RI Division of Taxation
One Capitol Hill - Suite 9
Providence, RI 02908-5811
Payments can be made online. For more information, visit: https://
If your estimate is zero or you make your payment online, you do not need to send in this estimated tax form.
2013
STATE OF RHODE ISLAND
T-69ES-SLB
DIVISION OF TAXATION * ONE CAPITOL HILL SUITE 9, PROVIDENCE, RI 02908-5811
Calendar Year
DECLARATION OF SURPLUS LINES BROKER ESTIMATED TAX
FOURTH ESTIMATE
NAME
1. TOTAL TAX FOR PRIOR
$
0 0
YEAR
ADDRESS
$
0 0
2. ESTIMATED TAX FOR
CURRENT YEAR
T-69ES-SLB
CITY, STATE, ZIP CODE
0 0
$
3. 100% OF LINE 2
FEDERAL EMPLOYER IDENTIFICATION NUMBER
4. LESS AMOUNT PAID OR
0 0
$
CREDITED TO DATE
I declare, under the penalties of perjury, that this document has been examined by me and,
to the best of my knowledge and belief, is true, and complete.
5. PAYMENT DUE WITH THIS
$
0 0
VOUCHER (LINE 3 LESS
LINE 4)
Signature of officer or agent
AMOUNT ON LINE 5 IS DUE AND PAYABLE ON OR BEFORE DECEMBER 31ST
Key #13
Title
Date
2013
STATE OF RHODE ISLAND
T-69ES-SLB
DIVISION OF TAXATION * ONE CAPITOL HILL SUITE 9, PROVIDENCE, RI 02908-5811
Calendar Year
DECLARATION OF SURPLUS LINES BROKER ESTIMATED TAX
THIRD ESTIMATE
NAME
1. TOTAL TAX FOR PRIOR
$
0 0
YEAR
ADDRESS
$
2. ESTIMATED TAX FOR
0 0
CURRENT YEAR
CITY, STATE, ZIP CODE
T-69ES-SLB
0 0
$
3. 75% OF LINE 2
FEDERAL EMPLOYER IDENTIFICATION NUMBER
4. LESS AMOUNT PAID OR
0 0
$
CREDITED TO DATE
I declare, under the penalties of perjury, that this document has been examined by me and,
to the best of my knowledge and belief, is true, and complete.
5. PAYMENT DUE WITH THIS
$
0 0
VOUCHER (LINE 3 LESS
LINE 4)
Signature of officer or agent
AMOUNT ON LINE 5 IS DUE AND PAYABLE ON OR BEFORE OCTOBER 31ST
Title
Date
Key #13
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