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4 State of Rhode Island Division of Taxation 4
5 Form IT-95 5
6 Informational Return of Insurance Companies 16160599990101 6
7 7
8 8
9 9
10 Decedent's first name MI Last name Suffix Decedent's social security number 10
11 XXXXXXXXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX XXX 999-99-9999 11
12 Decedent's address - Legal residence (domicile) at time of death City, town or post office State ZIP code 12
13 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XX 99999 13
14 14
15 15
16 Insurance company information Name: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 16
17 17
18 Address: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 18
19 19
20 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 20
21 21
22 Date of death XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 22
23 23
24 Type of contract XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 24
25 25
26 Name(s) of payee XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 26
27 27
28 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 28
29 29
30 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 30
31 Amount of proceeds if payable in 31
32 one sum XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 32
33 Value of proceeds if not paid in 33
34 one sum XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 34
35 35
36 36
Provisions of policy with respect XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
37 37
38 to the deferred payments or XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 38
39 installments 39
40 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 40
41 41
42 Owner of policy if not the insured XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 42
43 43
44 INSTRUCTIONS: 44
45 45
46 46
This form must be filed with the Rhode Island Division of Taxation within thirty (30) days of receipt of information
47 47
of the death of the insured where the payments made or to be made exceed fifity thousand ($50,000) dollars.
48 48
49 A SEPARATE STATEMENT MUST BE FILED FOR EACH INSURANCE CONTRACT 49
50 50
51 51
52 52
53 The undersigned officer of the above named insurance company hereby certifies that this statement is true and correct. 53
54 54
Auothorized signature Print name Date Telephone number
55 55
56 10/23/2020 (999) 999-9999 56
57 Address City, town or post office State ZIP Code PTIN 57
58 XXXXXXXXXXXXXX XX 99999 P99999999 58
59 59
60 60
61 61
62 Mail to RI Division of Taxation - One Capitol Hill - Providence, RI 02908 62
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Revised 10/2020