Form 63-23p - Premium Excise Return For Insurance Companies - 2012 Page 3

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Part 2. Gross Investment Income.
Domestic casualty insurers only must complete this schedule.
From NAIC Annual Statement, Form 2, Underwriting and Investment Exhibit, part I, col. 8, or Form 9, Operations and Investment Exhibit, part I, col. 8, for the
taxable year.
01 Interest on bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
02 Dividends on preferred stocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
03 Dividends on common stocks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
04 Interest on mortgage loans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
05 Real estate income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
06 Interest on collateral loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
07 Cash on deposit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
08 Other invested assets
a_________________________________________________________________________________________________ 8a
b_________________________________________________________________________________________________ 8b
c_________________________________________________________________________________________________ 8c
09 Total invested assets. Add lines 8a through 8c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Gross investment income. Add lines 1 through 7 and line 9. Enter result here and on page 1, line 2 . . . . . . . . . . . . . . . . . . . . 10
Part 3. Computation of Retaliatory Tax.
Foreign casualty insurers only must complete this schedule.
Use the space below to calculate your excise using the identical method and the same rate used by the state in which you are incorporated in taxing a like
Massachusetts insurance company, or its agents, if doing business to the same extent. If the computation in the state of your
incorporation is in every respect the same as your Massachusetts computation, a statement to that effect should be made . . . . . . 1

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