State of Rhode Island Division of Taxation 
        Form T-71SP 
        Self Procurement Insurance Premiums Return                                                13111899990101

   Name                                                                             Federal employer identification number/social security number

   Address                                                                          For the period ending:

   Address 2

   City, town or post office                       State        ZIP code            E-mail address

   CARRIER NAME                BROKER                                        POLICY 
(Company carrying the risk,                        TYPE OF COVERAGE                                        POLICY #                                                   PREMIUM
 not the wholesale broker)     (If applicable)                               EFFECTIVE DATE

   a

   b

   c

   d

   e

     Computation of Tax   
   1 Gross premium charged.  Enter the total of amounts in the “Premium” column above...............................................                                 1

   2 SELF PROCUREMENT TAX.  Multiply line 1 by the tax rate of 4% (0.04)..................................................................                           2

   3 Interest.  Rate: 12% per annum, 1% per month..........................................................................................................          3

   4 Total due with return.  Add lines 2 and 3...................................................................................................................... 4
                                 GENERAL INSTRUCTIONSDRAFT 
Return is due within thirty (30) days after procurement.  Enter the required information on lines                                                                     IMPORTANT:  
a, b, c, d and e in the table above.  Enter only the Rhode Island portion of the premium.                  
 
                                                                                                          Attach a copy of policy, covernote or other 
If more lines are needed, attach a separate sheet listing the required information.                       documentation supporting the amount(s) 
Line 1: Gross Premium Charged.  Add the amounts from lines a, b, c, d and e from the                      of coverage, effective date(s) and pre-
        Premium Column and enter here.                                                                    mium(s) for this policy.  If the premium 
 
Line 2: Self Procurement Tax.  Multiply line 1 by the tax rate of 4% (0.04).                              stated is an allocation premium, the basis 
                                                                                                          for allocation must be provided.  
Line 3: Interest on Tax Due.  12% per annum, 1% per month.                                                 
                                                                                                          Attach additional schedules as needed.
Line 4: Total Due with Return.  Add lines 2 and 3.
 Under penalties of perjury, I declare that I have examined09/07/2023this 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. 
                 See the Business Forms General Instructions for more information on the requirements and how to file and pay.                                                       Revised 
                                                                                                                                                                                     08/2023