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4 State of Rhode Island Division of Taxation 4
5 2024 Form T-71A 5
6 Surplus Line Broker Return of Gross Premiums 24111799990101 6
7 7
8 Name Federal employer identification number 8
9 9
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 999999999 10
11 Address State or country of incorporation or organization 11
12 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 12
13 Address 2 National producer number 13
14 14
15 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXX 15
City, town or post office State ZIP code E-mail address
16 16
17 XXXXXXXXXXXXXXXXXXXXXXXX XX 99999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 17
18 Initial 18
19 Return Final Amended 19
Return Return
Computation of Tax
20 20
21 1 Gross premium charged.......................................................................... 1 9999999999 99 21
22 2 Returned Premiums................................................................................. 2 9999999999 99 22
23 3 Net Taxable Premium. Subtract line 2 from line 1....................................................................................... 3 9999999999 99 23
Tax and 4 SURPLUS LINE BROKER TAX. Rate: 4%. Multiply line 3 by the tax rate of 4% (0.04)............................ 4
24 Payments 5 Payments made on 2024 declaration of estimated tax ........................... 5 9999999999 99 24
25 9999999999 99 25
26 Balance 6 Net Tax Due. Subtract line 5 from line 4..................................................................................................... 6 9999999999 99 26
Due 7 Interest Due: (a) Late payment _____________ (b) Underestimating __________ ................................. 7
27 9999999999 99 27
28 8 Total Due with Return. Add lines 6 and 7.................................................................................................... 8 9999999999 99 28
29 Refund 9 Overpayment. Subtract lines 4 and 7 from line 5....................................................................................... 9 9999999999 99 29
30 10 Amount of overpayment to be applied to 2025 estimated tax..................................................................... 10 9999999999 99 30
31 11 Amount to be refunded. Subtract line 10 from line 9.................................................................................. 11 9999999999 99 31
32 INSURANCE AGENCIES: 32
33 Enter the Federal Identification Number of the Agency ONLY in the space provided above. Do NOT enter a broker’s social security number. You 33
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
34 may be delayed. You may submit as many copies of page 2 as needed. 34
35 35
36 INDIVIDUALS: 36
37 Enter your National Producer Number in the space provided above. Do NOT enter the insurance agency’s federal identification number. 37
Skip page 2 and go directly to page 3.
38 38
39 Line 1: Gross Premium Charged - From the Return Supplement on Line 7: Interest Due: 39
page 3, add the Premium Column Total to the Additional (a) Late payment interest: 12% per annum, 1.0% per month.
40 Premium Column Total. (b) Underestimating interest - see Regulation 280-RICR-20-25-5. 40
41 Enter the sum of lines (a) and (b) on line 7. 41
42 Line 2: Amount of Returned Premiums - From theDRAFTReturn Supplement 42
43 on page 3, enter the amount from Return Premium Column Line 8: Total Due with Return. Add lines 6 and 7. 43
Total.
44 Line 9: Overpayment. Subtract lines 4 and 7 from line 5. 44
45 Line 3: Net Taxable Premium. Subtract line 2 from line 1. 45
46 Line 10: Enter the amount from line 9 to be applied to 2025 46
Line 4: Surplus Line Broker Tax. Multiply line 3 times rate of 4% (0.04). Estimated Tax.
47 47
48 Line 5: Enter the amount of estimated tax paid for tax year 2024, plus Line 11: Subtract line 10 from line 9. This is the amount to be refunded. 48
49 49
50 any amounts applied from tax year 2023. Submit Form T-71A and remit any payment due by April 1, 2025. 50
51 Line 6: Net Tax Due. Subtract line 5 from line 4. 51
52 52
Under penalties of perjury, I declare that I have examined10/01/2024this return and accompanying schedules and statements, and to the best of my knowledge and
53 belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. 53
54 Authorized officer signature Print name Date Telephone number 54
55 XXXXXXXXXXXXXXXXXXXXX 09/28/2020 (999) 999-9999 55
56 Paid preparer signature Print name Date Telephone number 56
57 57
58 XXXXXXXXXXXXXXXXXXXXX 09/28/2020 (999) 999-9999 58
59 Paid preparer address City, town or post office State ZIP code PTIN 59
60 XXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XX 99999 P99999999 60
61 61
62 May the Division of Taxation contact your preparer? YES 62
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Rhode Island has an Electronic Mandate for filing a return and remitting a payment. Revised
34567890123456789012345678901234567890123456789012345678901234567890123456789012See the Business Forms General Instructions for more information on the requirements and how to file and pay. 07/2024
