Enlarge image | State of Rhode Island Division of Taxation 2023 Form T-71A Surplus Line Broker Return of Gross Premiums 23111799990101 Name Federal employer identification number Address State or country of incorporation or organization Address 2 National producer number City, town or post office State ZIP code E-mail address Computation of Tax 1 Gross premium charged.......................................................................... 1 2 Returned Premiums................................................................................. 2 3 Net Taxable Premium. Subtract line 2 from line 1....................................................................................... 3 Tax and 4 SURPLUS LINE BROKER TAX. Rate: 4%. Multiply line 3 by the tax rate of 4% (0.04)............................ 4 Payments 5 Payments made on 2023 declaration of estimated tax ........................... 5 Balance 6 Net Tax Due. Subtract line 5 from line 4..................................................................................................... 6 Due 7 Interest Due: (a) Late payment _____________ (b) Underestimating __________ ................................. 7 8 Total Due with Return. Add lines 6 and 7.................................................................................................... 8 Refund 9 Overpayment. Subtract lines 4 and 7 from line 5....................................................................................... 9 10 Amount of overpayment to be applied to 2024 estimated tax..................................................................... 10 11 Amount to be refunded. Subtract line 10 from line 9.................................................................................. 11 INSURANCE AGENCIES: Enter the Federal Identification Number of the Agency ONLY in the space provided above. Do NOT enter a broker’s social security number. You MUST complete page 2, LIST OF BROKERS, in order for the individual broker licenses to be renewed. If page 2 is not completed, license renewals may be delayed. You may submit as many copies of page 2 as needed. INDIVIDUALS: Enter your National Producer Number in the space provided above. Do NOT enter the insurance agency’s federal identification number. Skip page 2 and go directly to page 3. Line 1: Gross Premium Charged - From the Return Supplement on Line 7: Interest Due: page 3, add the Premium Column Total to the Additional (a) Late payment interest: 12% per annum, 1.0% per month. Premium Column Total. (b) Underestimating interest - see Regulation 280-RICR-20-25-5. Enter the sum of lines (a) and (b) on line 7. Line 2: Amount of Returned Premiums - From the Return Supplement on page 3, enter the amount from Return Premium Column Line 8: Total Due with Return. Add lines 6 and 7. Total. Line 9: Overpayment. Subtract lines 4 and 7 from line 5. Line 3: Net Taxable Premium. Subtract line 2 from line 1. Line 10: Enter the amount from line 9 to be applied to 2024 Line 4: Surplus Line Broker Tax. Multiply line 3 times rate of 4% (0.04). Estimated Tax. Line 5: Enter the amount of estimated tax paid for tax year 2023, plus Line 11: Subtract line 10 from line 9. This is the amount to be refunded. any amounts applied from tax year 2022. Submit Form T-71A and remit any payment due by April 1, 2024. Line 6: Net Tax Due. Subtract line 5 from line 4. 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 belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Authorized officer signature Print name Date Telephone number Paid preparer signature Print name Date Telephone number Paid preparer address City, town or post office State ZIP code PTIN May the Division of Taxation contact your preparer? YES Rhode Island has an Electonic Mandate for filing a return and remitting a payment. Revised See the Business Forms General Instructions for more information on the requirements and how to file and pay. 08/2023 |
Enlarge image | State of Rhode Island Division of Taxation 2023 Form T-71A Surplus Line Broker Return of Gross Premiums 23111799990102 Name Federal employer identification number This page must be completed by agencies/companies with individual licensees covered under this return to prevent a delay in renewing the licenses of those individuals. SSN First MI Last name name National Broker #1 producer Address number SSN First MI Last name name National Broker #2 producer Address number SSN First MI Last name name National Broker #3 producer Address number SSN First MI Last name name National Broker #4 producer Address number SSN First MI Last name name National Broker #5 producer Address number SSN First MI Last name name National Broker #6 producer Address number SSN First MI Last name name National Broker #7 producer Address number SSN First MI Last name name National Broker #8 producer Address number SSN First MI Last name name National Broker #9 producer Address number SSN First MI Last name name National Broker #10 producer Address number SSN/FEIN: Signature of broker: Licensee: Page 2 |
Enlarge image | State of Rhode Island Division of Taxation 2023 Form T-71A Surplus Line Broker Return of Gross Premiums IMAGEONLY Name Federal employer identification number/social security number For policies invoiced from January 1, 2023 through December 31, 2023 Carrier Company carrying the risk, Name of Risk Invoice Return Additional NAIC# not the Wholesale Broker Premium Name Insured Location Date Premium Premium Premium totals - - - > SSN/FEIN: Signature of broker: Licensee: Page 3 |