Form Ig257 - Firefighter Relief Surcharge Return - 2012-2013

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IG257
2012–2013 Firefighter Relief Surcharge Return
For the period of (check one):
Nov 1, 2012 – March 31, 2013
April 1, 2013 – May 31, 2013
June 1, 2013 – Oct. 31, 2013
(Due April 30)
(Due June 30)
(Due Nov. 30)
Check if:
Amended return
No activity
Name of insurance company
FEIN
Minnesota tax ID (required)
Mailing address
Check if new address
NAIC number
State/country of incorporation
City
State
Zip code
Contact person
Email address
Website address
Daytime phone
Fax number
Rochester
Duluth
St. Paul
Minneapolis
1 Gross fire, lightning and sprinkler-
leakage premiums written (include
finance, service and other charges) . . . . 1
2 Premiums returned to insured,
including dividends . . . . . . . . . . . . . . . . . 2
3 Net fire, lightning and sprinkler-leakage
premiums (subtract line 2 from line 1) . 3
4 Surcharge by city
(multiply line 3 by 2% [.02]) . . . . . . . . . . . 4
5 Total surcharge due (or overpaid) (add amounts on 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 (make separate payments for each period):
Payment method:
Electronic payment
Check
(payable to Minnesota Revenue; write MN tax ID number on check; attach PV51)
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.
Authorized signature
Title
Date
Daytime phone
I authorize the Minnesota
Department of Revenue to
Signature of preparer
Print name of preparer
Date
Daytime phone
discuss this tax return with
the preparer.
Mail to: Minnesota Revenue, Mail Station 1780, St. Paul, MN 55145-1780

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