Form M19 - Insurance Premium Estimated Tax Payment

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Insurance Premium Estimated Tax Payment
M19
IMPORTANT:
Type in the required information while this form is on the screen and print a copy. A personalized scan
line will be printed on the voucher using the information you entered. To help ensure your payment is properly credited
to your account, verify that the period end date and Minnesota tax ID number are included in the scan line.
When you print this voucher, be sure to set the Page Scaling to “None” in your Print options. DO NOT check the “Auto-
rotate and center pages” or “Shrink to fit” boxes. If they are already checked, click on the box to uncheck them.
Pay Electronically
Pay by Credit or Debit Card
Before a Payment Can Be
• Go to and log
• Go to payMNtax.com; or
Made
in to e-Services; or
• Call 1‑855‑9‑IPAY‑MN.
To ensure your payment is processed cor-
• Call 1‑800‑570‑3329 to pay by phone.
rectly, you must have a Minnesota tax ID
You will be charged a fee to use this service,
number. To register for a Minnesota tax ID
which goes directly to Value Payment
You’ll need your username, password
number:
Systems (a national company that partners
and banking information. When paying
with federal, state and local governments to
electronically, you must use an account not
• Go to and
provide credit/debit card payment services).
associated with any foreign banks.
click “Register for a Minnesota tax ID
number” on the e-Services menu; or
After you authorize the payment, you’ll re-
The Department of Revenue does not have
• Register by phone at 651‑282‑5225 or
ceive a confirmation number. You can can-
any financial agreement with Value Payment
Systems and does not receive any of its fees.
1‑800‑657‑3605.
cel a payment up to one business day before
the scheduled payment date, if needed.
Pay by Check
Do not send in the voucher below unless
If you are not required to pay electroni-
you are paying by check.
cally, you may pay by check. Complete the
voucher below and mail it with your check.
All information is required to process your
payment, including your Minnesota tax ID
number.
When you pay by check, your check autho-
rizes us to make a one-time electronic fund
transfer from your account, and you may
not receive your cancelled check.
Cut carefully along this line to detach.
M19
076
Insurance Premium Estimated Tax Payment
Minnesota Tax ID
(required)
Name of insurance company
Mailing address
NAIC Number
Enter the last day of the period. Use
City
State
ZIP code
mmddyy format.
Period End Date
u
Example: If making a 2013 estimated
(mmddyy)
Name of contact person
Phone
tax payment, enter 123113 for all four
quarters.
Make check payable to Minnesota Revenue and mail to:
AMOUNT
Minnesota Revenue, Mail Station 1785, St. Paul, MN 55145-1785
OF CHECK
00
To help ensure your payment is properly credited to your account, be sure to verify that the scan line below includes the correct period end date and your Minnesota tax ID.
0760000000000000000000123110000000
000000
0000000000000000000000002

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