Form T-71a - Surplus Line Broker Return Of Gross Premiums - 2012
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3State of Rhode Island and Providence Plantations
Form T-71A
SURPLUS LINE BROKER RETURN OF GROSS PREMIUMS
SURPLUS LINE
for Calendar Year Ending December 31, 2012
2012
Due on or before April 1, 2013
NAME
ADDRESS
CITY
STATE
ZIP CODE
FEDERAL EMPLOYER IDENTIFICATION NUMBER/SOCIAL SECURITY NUMBER
E-MAIL ADDRESS
STATE OR COUNTRY OF INCORPORATION OR ORGANIZATION
BROKER LICENSE NUMBER
Computation of Tax
1.
1.
Gross premium charged .........................................................................................................
2.
2.
Returned Premiums ................................................................................................................
3.
3.
Net Taxable Premium. Subtract line 2 from line 1...........................................................................................................
Tax and
.
.
SURPLUS LINE BROKER TAX. Rate: 4%. Multiply line 3 by the tax rate of 4% (0.04)...............................................
4
4
Payments
5.
5.
Payments made on 2012 Declaration of Surplus Line Brokers Estimated Tax ......................
Balance Due
6.
6.
Net Tax Due. Subtract line 5 from line 4.........................................................................................................................
7.
Interest Due: (a) Late payment:18% per annum (1.5% per month)_____________ (b) Underestimating:__________
7.
8.
Total Due with Return. Add lines 6 and 7 .......................................................................................................................
8.
Refund
9.
9.
Overpayment. Subtract lines 4 and 7 from line 5............................................................................................................
10.
Amount to be applied to estimated tax for calendar year 2013.......................................................................................
10.
11.
Amount to be Refunded. Subtract line 10 from line 9.....................................................................................................
11.
GENERAL INSTRUCTIONS
NOTE: IF THIS RETURN IS COMPLETED ON A COMPANY BASIS, PLEASE INCLUDE A LIST OF BROKERS ON PAGE 3.
Line 1:
Gross Premium Charged - From the Return Supplement on
Line 7:
Interest Due:
page 2, add the Premium Column Total to the Additional
(a) Late payment interest: 18% per annum, 1.5% per month.
Premium Column Total.
(b) Underestimating interest - see Regulation CT01-10.
Enter the sum of lines (a) and (b) on line 7.
Line 2:
Amount of Returned Premiums - From the Return Supplement
on page 2, enter the amount from Return Premium Column Total.
Line 8:
Total Due with Return. Add lines 6 and 7.
Line 3:
Net Taxable Premium. Subtract line 2 from line 1.
Line 9:
Overpayment. Subtract lines 4 and 7 from line 5.
Line 4:
Surplus Line Broker Tax. Multiply line 3 times rate of 4% (0.04).
Line 10: Enter the amount from line 9 to be applied to 2013
Declaration of Estimated Tax.
Line 5:
Enter the amount of estimated tax paid for tax year 2012, plus
any amounts applied from tax year 2011.
Line 11: Subtract line 10 from line 9. This is the amount to be refunded.
Line 6:
Net Tax Due. Subtract line 5 from line 4.
CERTIFICATION: This certification must be executed or the return must be sworn before some person authorized to administer oaths.
Under penalties of perjury, I hereby certify that I have personal knowledge of the statements and other information constituting this return, that the same are true, correct
and complete to the best of my knowledge and belief.
Date
Signature of authorized officer
Title
Date
Signature of preparer
Address of preparer
MAY THE DIVISION CONTACT YOUR PREPARER ABOUT THIS RETURN? YES
NO
Phone number
MAILING ADDRESS: RI DIVISION OF TAXATION, ONE CAPITOL HILL, PROVIDENCE, RI 02908-5811
Key #13
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