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4 State of Rhode Island Division of Taxation 4
5 Form T-71SP 5
6 Self Procurement Insurance Premiums Return 13111899990101 6
7 7
8 Name Federal employer identification number/social security number 8
9 9
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99999999999 10
11 Address For the period ending: 11
12 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 12312023 12
13 Address 2 13
14 14
15 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 15
City, town or post office State ZIP code E-mail address
16 16
17 XXXXXXXXXXXXXXXXXXXXXXXXXX XX 99999 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 17
18 18
19 19
20 CARRIER NAME BROKER POLICY 20
21 (Company carrying the risk, TYPE OF COVERAGE POLICY # PREMIUM 21
not the wholesale broker) (If applicable) EFFECTIVE DATE
22 22
23 23
24 a XXXXXXXX XXXXXXXXXX XXXXXXXXX 12312023 XXXXXXXXX 99999999 99 24
25 25
26 b XXXXXXXX XXXXXXXXXX XXXXXXXXX 12312023 XXXXXXXXX 99999999 99 26
27 27
28 c XXXXXXXX XXXXXXXXXX XXXXXXXXX 12312023 XXXXXXXXX 99999999 99 28
29 29
30 d XXXXXXXX XXXXXXXXXX XXXXXXXXX 12312023 XXXXXXXXX 99999999 99 30
31 31
32 e XXXXXXXX XXXXXXXXXX XXXXXXXXX 12312023 XXXXXXXXX 99999999 99 32
33 Computation of Tax 33
34 34
1 Gross premium charged. Enter the total of amounts in the “Premium” column above............................................... 1
35 99999999 99 35
36 36
2 SELF PROCUREMENT TAX. Multiply line 1 by the tax rate of 4% (0.04).................................................................. 2
37 99999999 99 37
38 38
3 Interest. Rate: 12% per annum, 1% per month.......................................................................................................... 3
39 99999999 99 39
40 40
4 Total due with return. Add lines 2 and 3...................................................................................................................... 4
41 99999999 99 41
42 GENERAL INSTRUCTIONSDRAFT 42
43 Return is due within thirty (30) days after procurement. Enter the required information on lines IMPORTANT: 43
44 a, b, c, d and e in the table above. Enter only the Rhode Island portion of the premium. 44
45 Attach a copy of policy, covernote or other 45
If more lines are needed, attach a separate sheet listing the required information. documentation supporting the amount(s)
46 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- 46
47 Premium Column and enter here. mium(s) for this policy. If the premium 47
48 Line 2: Self Procurement Tax. Multiply line 1 by the tax rate of 4% (0.04). stated is an allocation premium, the basis 48
49 for allocation must be provided. 49
Line 3: Interest on Tax Due. 12% per annum, 1% per month.
50 Attach additional schedules as needed. 50
51 Line 4: Total Due with Return. Add lines 2 and 3. 51
52 52
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
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 55
56 Paid preparer signature Print name Date Telephone number 56
57 57
58 58
59 Paid preparer address City, town or post office State ZIP code PTIN 59
60 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.
34567890123456789012345678901234567890123456789012345678901234567890123456789012See the Business Forms General Instructions for more information on the requirements and how to file and pay. Revised
08/2023