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4          State of Rhode Island Division of Taxation                                                                                                                                     4
5          2023 Form T-71A                                                                                                                                                                5
6          Surplus Line Broker Return of Gross Premiums                                                                23111799990101                                                     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                                                                                                                                                                                       18
19                                                                                                                                                                                       19
   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 2023 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 2024 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 2024                                    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 2023, 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 2022.                                         Submit Form T-71 and remit any payment due by April 1, 2024.                                  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 examined09/08/2023this 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 Electonic 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. 08/2023

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4             State of Rhode Island Division of Taxation                                                                4
5             2023 Form T-71A                                                                                           5
6             Surplus Line Broker Return of Gross Premiums          23111799990102                                      6
7                                                                                                                       7
8  Name                                                        Federal employer identification number                   8
9                                                                                                                       9
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                    99-9999999                                               10
11                      This page must be completed by agencies/companies with individual licensees covered under this  11
12                                 return to prevent a delay in renewing the licenses of those individuals.             12
13                                                                                                                      13
                                    name                            name
14            SSN 999-99-9999       First XXXXXXXXXXXXXX       MI X Last XXXXXXXXXXXXXXXXXXX                            14
15            National                                                                                                  15
16 Broker #1  producer 999999999    Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  16
              number 
17                                                                                                                      17
                                    name                            name
18            SSN 999-99-9999       First XXXXXXXXXXXXXX       MI X Last XXXXXXXXXXXXXXXXXXX                            18
19            National                                                                                                  19
20 Broker #2  producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  20
              number
21                                                                                                                      21
                                    name                            name
22            SSN 999-99-9999       First XXXXXXXXXXXXXX       MI X Last XXXXXXXXXXXXXXXXXXX                            22
23            National                                                                                                  23
24 Broker #3  producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  24
              number
25                                                                                                                      25
                                    name                            name
26            SSN 999-99-9999       First XXXXXXXXXXXXXX       MI X Last XXXXXXXXXXXXXXXXXXX                            26
27            National                                                                                                  27
28 Broker #4  producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  28
              number
29                                                                                                                      29
              SSN                   First                      MI   Last 
30                999-99-9999       name  XXXXXXXXXXXXXX          X name XXXXXXXXXXXXXXXXXXX                            30
31            National                                                                                                  31
32 Broker #5  producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  32
              number
33                                                                                                                      33
              SSN                   First                      MI   Last 
34                999-99-9999       name  XXXXXXXXXXXXXX          X name XXXXXXXXXXXXXXXXXXX                            34
35            National                                                                                                  35
36 Broker #6  producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  36
              number
37                                                                                                                      37
              SSN                   First                      MI   Last 
38                999-99-9999       name  XXXXXXXXXXXXXX          X name XXXXXXXXXXXXXXXXXXX                            38
39            National                                                                                                  39
40 Broker #7  producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  40
              number
41                                                                                                                      41
              SSN                   First                      MI   Last 
42                999-99-9999       DRAFTname XXXXXXXXXXXXXX      X name XXXXXXXXXXXXXXXXXXX                            42
43            National                                                                                                  43
44 Broker #8  producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  44
              number
45                                                                                                                      45
                                    name                            name
46            SSN 999-99-9999       First XXXXXXXXXXXXXX       MI X Last XXXXXXXXXXXXXXXXXXX                            46
47            National                                                                                                  47
48 Broker #9  producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  48
              number
49                                                                                                                      49
                                    name                            name
50            SSN 999-99-9999       First XXXXXXXXXXXXXX       MI X Last XXXXXXXXXXXXXXXXXXX                            50
51            National                                                                                                  51
52 Broker #10 producer  999999999   Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  52
              number                      09/08/2023
53                                                                                                                      53
54            SSN/FEIN: 999-99-9999                                                                                     54
55                                                                                                                      55
56            Signature of broker:                                                                                      56
57                                                                                                                      57
58            Licensee: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                        58
59                                                                                                                      59
60                                                                                                                      60
61                                                                                                                      61
62                                                                                                                      62
                                                         Page 2
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4       State of Rhode Island Division of Taxation                                                                               4
5       2023 Form T-71A                                                                                                          5
6       Surplus Line Broker Return of Gross Premiums                       IMAGEONLY                                             6
7                                                                                                                                7
8  Name                                                            Federal employer identification number/social security number 8
9                                                                                                                                9
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                        999-99-9999                                                   10
11                                                                                                                               11
                        For policies invoiced from January 1, 2023 through December 31, 2023
12                                                                                                                               12
13           Carrier Company carrying the risk, Name of       Risk Invoice                  Return  Additional                   13
14 NAIC#             not the Wholesale Broker                                    Premium                                         14
             Name                               Insured   Location Date                     Premium Premium
15                                                                                                                               15
16 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       16
17                                                                                                                               17
18 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       18
19                                                                                                                               19
20 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       20
21                                                                                                                               21
22 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       22
23                                                                                                                               23
24 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       24
25                                                                                                                               25
26 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       26
27                                                                                                                               27
28 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       28
29                                                                                                                               29
30 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       30
31                                                                                                                               31
32 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       32
33                                                                                                                               33
34 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       34
35                                                                                                                               35
36 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       36
37                                                                                                                               37
38 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       38
39                                                                                                                               39
40 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       40
41                                                                                                                               41
42 999999 XXXXXXXXXXXXXXXXXXDRAFTXXXXXXXXX XXXXXX 9999999                        999999 999999      999999                       42
43                                                                                                                               43
44 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       44
45                                                                                                                               45
46 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       46
47                                                                                                                               47
48 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       48
49                                                                                                                               49
50 999999 XXXXXXXXXXXXXXXXXX                    XXXXXXXXX XXXXXX 9999999         999999 999999      999999                       50
51                                                                                                                               51
52                                                        Premium totals - - - > 999999 999999      999999                       52
                                              09/08/2023
53                                                                                                                               53
54 SSN/FEIN: 999-99-9999                                                                                                         54
55                                                                                                                               55
56 Signature of broker:                                                                                                          56
57                                                                                                                               57
58 Licensee: 9999999999999999999999999999                                                                                        58
59                                                                                                                               59
60                                                                                                                               60
61                                                                                                                               61
62                                                                                                                               62
                                                        Page 3
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