FILING FOR MARCH 1, 2010 FEDERAL IDENTIFICATION NO. _____________________ The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 TAX DISCLOSURE REPORT Domestic Life Insurance Companies 1. Exact name of insurance company:_______________________________________________________________________________ 2. Location, including street address, of the insurance company’s principal office: _____________________________________________ ____________________________________________________________________________________________________________ I, _________________________________________, the undersigned *Treasurer / *Assistant Treasurer, of the above-named company, do hereby certify that all the information contained herein is true and correct as of the date shown below. SIGNED UNDER THE PENALTIES OF PERJURY, this __________ day of________________________________ , 20 ___________. __________________________________________________________________________________ , *Treasurer / *Assistant Treasurer (signature) TAX DISCLOSURE REPORT Domestic Life Insurance Companies 3. Tax year for which the report is filed: .............................................................................................................. _____________________ 4. Gross receipts or sales: ................................................................................................................................... $ _____________________ 5. Income subject to apportionment:................................................................................................................. $ _____________________ 6. Premiums and income taxable in Massachusetts: ........................................................................................... $ _____________________ 7. Total Massachusetts excise or tax due: ............................................................................................................ $ _____________________ 8. Set forth the amount of each tax credit taken: ______________________________________________________________________ *Delete the inapplicable words. Note: You may furnish supplemental information in accordance with M.G.L. Ch 62C, s.83(j) on separate 81/2 x 11 sheets of white bond paper. American LegalNet, Inc. www.FormsWorkFlow.com tdrdlic 2/4/10 In these instructions, all references to Massachusetts tax forms refer to 2007 forms. If you are using forms for any other year when supplying information, be sure that you include the substantive information required by statute. Forms for other years may be numbered differently. INSTRUCTIONS FOR COMPLETION OF THIS FORM Note: The information for this filing must come from your most recently filed tax return or other document filed on or before June 30, 2009. Please type or print clearly in ink as this document will be microfilmed. Incomplete or incorrect reports will be returned to sender for completion and/or correction. Please send original document only; keep a photocopy for your files. A. Insert Federal Identification Number (employer’s I.D.) at upper right-hand corner. If you do not have one, you must apply to the Internal Revenue Service. B. Item 1. Insert the exact name of the insurance company as it appears on the Articles of Organization or subsequent amendments. Do not use any d/b/a names, trade names, or abbreviations. C. Item 2. Insert the full address of the insurance company’s principal office, using number and street, city or town, state and zip code. D. Complete the statement by inserting the name of the treasurer/assistant treasurer completing this form. Date and sign where indicated, and insert title. The officer who prepares this report must be the one who signs it. In the absence of the treasurer/assistant treasurer, the report may be signed by the president, vice-president, or clerk. E. Item 3. Insert the last day, month and year of the tax year for which the report is filed. F. Item 4. Insert the gross receipts or sales as reported on the company’s National Association of Insurance Commissioners Annual Statement, determined by adding the amounts reported in Columns 3, 4 and 5, of Line 99 of Schedule T of said statement and the amounts reported on the summary of operations on Lines 2 and 8 of page 4 of said statement. G. Item 5. Insert the amount of income subject to apportionment as reported on Schedule DL-2A. H. Item 6. Insert the amount of premiums and income taxable in Massachusetts as determined by adding Items 10 and 11 of Part 1 of Form 63-20P. I. Item 7. Insert the total Massachusetts excise or tax due as reported on Item 32 of Form 63-20P. J. Item 8. Insert the amount of each tax credit taken against the excise imposed by Massachusetts General Laws, Chapter 63 as reported on Form 63-20P. American LegalNet, Inc. www.FormsWorkFlow.com tdrdlic 2/4/10