Form Ig255 - Nonadmitted Insurance Premium Tax Return For Direct Procured Insurance - 2012

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IG255
2012 Nonadmitted Insurance Premium Tax Return for Direct Procured Insurance
Due March 1, 2013
Check if:
Amended return
No activity
Name of insured
Check if new address
Minnesota tax ID (required)
Contact person
Mailing address
Daytime phone
Fax number
City
State
Zip code
Email address
Website address
I am licensed to obtain insurance from nonadmitted insurers
Check if you are a purchasing group
from
to
1 Total gross premiums paid (from page 2, Column G) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Total return premiums received (from page 2, Column H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Taxable gross premiums paid (subtract line 2 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
.02
4 Tax rate is 2% (0 .02) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Total gross premiums tax due (multiply line 3 by line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 TOTAL AMOUNT DUE (or overpaid) (add lines 5 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
If you owe additional tax:
Payment method:
Electronic payment
Check
(payable to Minnesota Revenue; write MN tax ID number on check; attach PV58)
Enter amount paid
Date paid
(If amount paid is different from amount due on line 8, attach an explanation.)
If you overpaid: Overpayments will be refunded .
I declare that this return is correct and complete to the best of my knowledge and belief.
Signature of insured or officer of corporation
Date
Daytime phone
I authorize the
Minnesota Department
of Revenue to discuss
Signature of preparer
Print name of preparer
Date
Daytime phone
this tax return with the
preparer .
Mail to: Minnesota Revenue, Mail Station 1780, St . Paul, MN 55145-1780

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