Form Ig263 - Joint Self-Insurance Tax Return - 2012

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IG263
2012 Joint Self-Insurance Tax Return
Due March 1, 2013
Tax year beginning
2012, and ending
Check if:
Amended return
No activity
Name of joint self-insurance group
Check if new address
FEIN
Minnesota tax ID (required)
Mailing address
Contact person
City
State
Zip code
Daytime phone
Fax number
Email address
Website address
For plans operating under:
Chapter 60F
Chapter 62H
Round amounts to the nearest whole dollar
1 Claims paid, with no deduction for claims wholly or partially
reimbursed through stop-loss insurance:
a Ch. 60F plans: Enter total claims paid during the fund year . . . . . . . 1a
b Ch. 62H plans: Enter total claims paid during the fund’s fiscal year . . 1b
Total claims paid (add lines 1a and 1b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2%
2 Tax percentage rate is 2% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Tax liability (multiply line 1 by line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 TOTAL AMOUNT DUE (add lines 3 through 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Make check payable to Minnesota Revenue . Write your Minnesota tax ID on the check and include PV59 .
Enter amount paid
Date paid
(If amount paid is different from line 6, attach an explanation.)
I declare that this return is correct and complete to the best of my knowledge and belief. I confess judgment to the state of
Minnesota for the amount of tax shown due to the extent not timely paid.
Authorized signature
Title
Date
Daytime phone
I authorize the Minnesota
Department of Revenue to
discuss this tax return with
Signature of preparer
Print name of preparer
Date
Daytime phone
the preparer .
Mail to: Minnesota Revenue, Mail Station 1780, St . Paul, MN 55145-1780

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