Rhode Island 2015 Self Procurement Insurance Premiums Return

2015 Self Procurement Insurance Premiums Return
Microsoft Word - Incentive and Credit Overview for DLT
State of Rhode Island Division of Taxation

Form T-71SP
13111899990101

Self Procurement Insurance Premiums Return
Name

Federal employer identification number/social security number

Address

For the period ending:

Address 2

City, town or post office

State

CARRIER NAME

BROKER

(Company carrying the risk,
not the wholesale broker)

(If applicable)

ZIP code

TYPE OF COVERAGE

E-mail address

POLICY

POLICY #

EFFECTIVE DATE

PREMIUM

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, 1.5% per month.......................................................................................................

3

4 Total due with return. Add lines 2 and 3......................................................................................................................

4

GENERAL INSTRUCTIONS
Return is due within thirty (30) days after procurement. Enter the required information on lines
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
documentation supporting the amount(s)
of coverage, effective date(s) and premium(s) for this policy. If the premium
stated is an allocation premium, the basis
for allocation must be provided.

If more lines are needed, attach a separate sheet listing the required information.
Line 1:

Gross Premium Charged. Add the amounts from lines a, b, c, d and e from the
Premium Column and enter here.

Line 2:

Self Procurement Tax. Multiply line 1 by the tax rate of 4% (0.04).

Line 3:

Interest on Tax Due. 12% per annum, 1.5% per month.

Line 4:

Total Due with Return. Add lines 2 and 3.

IMPORTANT:

Attach additional schedules as needed.
Under penalties of perjury, I declare that I have examined this 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

Paid preparer address

Print name

City, town or post office

May the Division of Taxation contact your preparer? YES

Date

State

Telephone number

ZIP code

Revised 08/2022

PTIN

Key #13