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4                                 State of Rhode Island Division of Taxation                                                                                                                                            4
5                                 2022 Form T-71                                                                                                                                                                        5
6                                 Insurance Companies Tax Return of Gross Premiums                                                                    22111699990101                                                    6
7                                                                                                                                                                                                                       7
8                              Insurance      Name                                                                                                    Federal employer identification number                            8
9                              Company                                                                                                                                                                                  9
10                                                                                                                                                                                                                      10
                               Nonprofit Hos- AddressXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                               99-9999999State or country of incorporation or organization
11                             pital Service                                                                                                                                                                            11
12                             Corp, Non-     XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                      XXXXXXXXXXXXXXXXXXXXXXXXX                                         12
                               profit Dental 
13                             Corp, Non-     Address 2                                                                                               Company type: stock, mutual or participating                      13
14                             profit Medical                                                                                                                                                                           14
15                             Service Corp   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                      XXXXXXXXXXXXXXXXXXXXXXXXX                                         15
16                             and HMO        City, town or post office                           State                                      ZIP code E-mail address                                                    16
17                             Amended        XXXXXXXXXXXXXXXXXXXX                                XX                                         99999    XXXXXXXXXXXXXXXXXXXXXXXXX                                         17
18                                                                                                                                                                                                                      18
19                                                                                                                                                                                                                      19
                                                                          ATTACH LEGIBLE COPY OF SCHEDULE T AND SCHEDULE OF DIRECT BUSINESS IN THIS 
20                  Schedule A - Computation of Tax                       STATE FROM THE ANNUAL STATEMENT SUBMITTED TO THE INSURANCE COMMISSIONER                                                                       20
21                                                                                                                                                                                                                      21
22                           1 a Direct premiums (Gross premiums less return premiums from                                                                                                                              22
23                                Sch. T, Part 1 of Annual Statement to Insurance Commissioner)..                                         1a 9999999999 99                                                              23
24                             b Reinsurance assumed from companies not authorized to do                                                  1b                                                                            24
25                                business in Rhode Island (covering property and risks in RI)........                                       9999999999 99                                                              25
26                                                                                                                                                                                                                      26
27                           2    TOTAL PREMIUMS.  Add lines 1a and 1b .....................................................................................................   2   9999999999 99                        27
28                           3  a Dividends paid or credited to policyholders - Direct (Mutual &                                          3a                                                                            28
29                                Mutual Plan Companies Only)...........................................................                     9999999999 99                                                              29
30                             b                                                                                                                                                                                        30
                                  less return premiums)....................................................................
31                                Federally exempt premiums.  See instructions. (Gross premiums                                           3b 9999999999 99                                                              31
32                                                                                                                                                                                                                      32
33                             c Capital investments deduction.......................................................                     3c 9999999999 99                                                              33
          Deductions
34                             d Tax Incentives for Employers deduction - RIGL §44-55.                                                    3d                                                                            34
35                                Attach Form RI-107........................................................................                 9999999999 99                                                              35
36                                                                                                                                                                                                                      36
37                           4    TOTAL DEDUCTIONS.  Add lines 3a, 3b, 3c and 3d.....................................................................................          4   9999999999 99                        37
38                                                                                                                                                                                                                      38
39                           5    Net taxable premium.  Subtract line 4 from line 2........................................................................................... 5   9999999999 99                        39
40                                                                                                                                                                                                                      40
41                           6a Rhode Island tax.  Multiply line 5 by the tax rate of 2% (0.02)......                                     6a 9999999999 99                                                              41
42                                                                        DRAFT                                                                                                                                         42
43                             b Tax that would be imposed by taxpayer’s state or country.............                                    6b 9999999999 99                                                              43
44                                                                                                                                                                                                                      44
45                           7    TOTAL TAX DUE.  Line 6a or 6b, whichever is greater..................................................................................        7   9999999999 99                        45
46                           8  a RI Credits from Schedule B-CR, Business Entity Credit Schedule,                                                                                                                       46
47                                line 18................................................................................................ 8a 9999999999 99                                                              47
48                                                                                                                                                                                                                      48
49        Tax and Fee Amount   b Life and Health Guaranty Fee........................................................                     8b 9999999999 99                                                              49
50                                                                                                                                                                                                                      50
51                           9    TOTAL CREDITS.  Add lines 8a and 8b......................................................................................................... 9   9999999999 99                        51
52                                                                                                                                                                                                                      52
                                                                               09/08/2022
53                           10a TAX AFTER CREDITS. Subtract line 9 from line 7. If zero or less, enter zero...............................................                    10a 9999999999 99                        53
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4                            State of Rhode Island Division of Taxation                                                                                                                       4
5                            2022 Form T-71                                                                                                                                                   5
6                            Insurance Companies Tax Return of Gross Premiums                                              22111699990102                                                     6
7                                                                                                                                                                                             7
8                 Name                                                                                                     Federal employer identification number                             8
9                                                                                                                                                                                             9
10          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                             99-9999999                                                         10
11                                                                                                                                                                                            11
12                                                                                                                                                                                            12
13                                                                                                                                                                                            13
14                10b TAX AFTER CREDITS from line 10a..............................................................................................................   10b 9999999999 99       14
15                11a Payments made on 2022 BUS-EST, Business Tax                                                                                                                             15
16                   Estimated Payment........................................................................   11a 9999999999 99                                                            16
17                                                                                                                                                                                            17
18                b Other payments.............................................................................. 11b 9999999999 99                                                            18
19                                                                                                                                                                                            19
20    Payments    12 TOTAL PAYMENTS.  Add lines 11a and 11b..................................................................................................         12  9999999999 99       20
21                                                                                                                                                                                            21
22                13 Previously issued overpayments (if filing an amended return).......................................................................              13  9999999999 99       22
23                                                                                                                                                                                            23
24                14 Net Payments. Subtract line 13 from line 12...................................................................................................   14  9999999999 99       24
25                                                                                                                                                                                            25
26                15 Net tax due.  Subtract line 14 from line 10b.................................................................................................... 15                    9926
27                                                                                                                                                                                            27
28                16 Interest due: (a) Late payment interest ___________ (b) Underestimating interest ___________ Total (a) + (b) ....                                16  9999999999 99       28
29    Balance Due                                                                                                                                                                             29
30                17 TOTAL DUE WITH RETURN.  Add lines 15 and 16.......................................................................................               17  9999999999 99       30
31                                                                                                                                                                                            31
32                18 Overpayment.  Subtract lines 10b and 16 from line 14...................................................................................          18  9999999999 99       32
33                                                                                                                                                                                            33
34                19 Amount of overpayment to be applied to 2023 estimated tax.........................................................................               19  9999999999 99       34
      Refund
35                                                                                                                                                                                            35
36                20 Amount to be refunded.  Subtract line 19 from line 18....................................................................................        20  9999999999 99       36
37                                                                                                                                                                                            37
38                                                                                                                                                                                            38
39                                                            IMPORTANT INFORMATION                                                                                                           39
40                                                                                                                                                                                            40
41                              Mail Form T-71 with any payment due to: RI Division of Taxation - One Capitol Hill - Providence, RI 02908                                                     41
42                              Form T-71 is due on or before April 15, 2023. DRAFT                                                                                                           42
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52                Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and                       52
                  belief, it is true, accurate and complete.  Declaration of09/08/2022preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
53                                                                                                                                                                                            53
             Authorized officer signature                                   Print name                                                  Date                              Telephone number
54                                                                                                                                                                                            54
55                                                            XXXXXXXXXXXXXXXXXXXXX                                        09/28/2020                                 (999) 999-9999          55
56           Paid preparer signature                                        Print name                                                  Date                              Telephone number    56
57                                                            XXXXXXXXXXXXXXXXXXXXX                                        09/28/2020                                 (999) 999-9999          57
58           Paid preparer address                            City, town or post office                              State           ZIP code                                          PTIN   58
59                                                                                                                                                                                            59
60          XXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXX                                                                    XX    99999                                      P99999999               60
61                                                                                                                                                                                            61
62                                    May the Division of Taxation contact your preparer?   YES                                                                                               62
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