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 theDRAFTReturn 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 examined10/12/2023this 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

           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 
                               DRAFTname                       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                    10/12/2023
           SSN/FEIN:

           Signature of broker:

           Licensee:

                                                      Page 2

     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

                     DRAFT 

                                                    Premium totals - - - >
                                          10/12/2023
SSN/FEIN:

Signature of broker:

Licensee:

                                                    Page 3