Form T-71h - Health Insurance Companies Tax Return Of Gross Premiums - 2012
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1Form T-71H
State of Rhode Island and Providence Plantations
HEALTH INSURANCE COMPANIES TAX RETURN OF GROSS PREMIUMS
HEALTH
for Calendar Year Ending December 31, 2012
INSURANCE
Due on or before March 1, 2013
2012
NAME
ADDRESS
CITY
STATE
ZIP CODE
FEDERAL EMPLOYER IDENTIFICATION NUMBER
E-MAIL ADDRESS
.
STATE OR COUNTRY OF INCORPORATION OR ORGANIZATION
COMPANY TYPE
.
THIS FORM IS TO BE USED BY NONPROFIT HOSPITAL SERVICE CORPORATIONS, NONPROFIT DENTAL CORPORATIONS,
NONPROFIT MEDICAL SERVICE CORPORATIONS AND HEALTH MAINTENANCE ORGANIZATIONS
NOTE: ATTACH LEGIBLE COPY OF SCHEDULE T AND SCHEDULE OF DIRECT BUSINESS IN THIS STATE FROM THE
ANNUAL STATEMENT SUBMITTED TO THE INSURANCE COMMISSIONER
Tax Computation
Tax and Fee
Direct Premiums (Gross premiums less return premiums from Schedule T, Part 1 of Annual Statement to Insurance
.
.
1
1
Commissioner) .................................................................................................................................................................
Amount
.
TAX. Rate: 2.0%. Multiply line 1 by the tax rate of 2.0% (0.02).....................................................................................
2.
2
Credits and
.
.
RI Credits: Form #__________ $________ Form #__________ $__________ Form #__________ $____________
3
3
Payments
4.
TAX AFTER CREDITS. Subtract line 3 from line 2.........................................................................................................
4.
5.
Payments made on 2012 Declaration of Estimated Tax .........................................................
5.
6.
Other payments........................................................................................................................
4.
6.
7.
TOTAL PAYMENTS. Add lines 5 and 6 ..........................................................................................................................
7.
Balance Due
8.
Net Tax Due. Subtract line 7 from line 4.........................................................................................................................
8.
9.
Interest Due: (a) Late payment:18% per annum (1.5% per month)_____________ (b) Underestimating:__________
9.
10.
Total due with return. Add lines 8 and 9..........................................................................................................................
10.
Refund
11.
Overpayment. Subtract lines 4 and 9 from line 7...........................................................................................................
11.
12.
Amount of overpayment to be applied to Estimated Tax for 2013 calendar year............................................................
12.
13.
Amount to be refunded. Subtract line 12 from line 11....................................................................................................
13.
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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