Free CT-33-D - New York

Staple forms here

CT-33-D
(8/08)
Amended return

New York State Department of Taxation and Finance

Tax on Premiums Paid or Payable To an Unauthorized Insurer
Tax Law -- Article 33-A
Term of insurance policy effective or renewed from Telephone number to
For Tax Department use only

Employer identification number or social security number of insured Name of insured Number and street or PO box City State

(
ZIP code

)

Type of organization (mark an X in one box) Corporation Partnership Individual Other:
Payment enclosed

A. Pay amount shown on line 10. Make payable to: Commissioner of Taxation and Finance. Include on the payment your identification number, Form CT-33-D, and the calendar quarter for which you are reporting. (See instructions for details.)

A.

Part 1 -- Tax computation
1 Premiums paid or payable on risks located entirely within New York State .................................. 1. 2a Premiums paid or payable on risks located within and outside New York State ...................................................................... 2a. 2b Allocated portion of premiums from line 2a (see instructions) ........................................................... 2b. 3 Total taxable premiums (add lines 1 and 2b) ..................................................................................... 3. 4 Tax rate of 3.6% ................................................................................................................................ 4. 5 Tax due (multiply line 3 by line 4) ........................................................................................................ 5. 6 Prepayment ....................................................................................................................................... 6. 7 Balance (if line 5 is greater than line 6, subtract line 6 from line 5) ............................................................ 7. 8 Interest on late payment ................................................................................................................. 8. 9 Penalties ......................................................................................................................................... 9. 10 Total payment due (add lines 7, 8, and 9 and enter here; enter the payment amount on line A above) ......... 10. 11 Overpayment (if line 5 is less than line 6, subtract line 5 from line 6) Credit to next period Refund 11.

0.036

Part 2 -- Insurer information (attach additional sheets if necessary)
Name of insurance company Broker's name Broker's telephone number

(
Number and street or PO box of insurance company City State

)
ZIP code

Certification: I certify that this return and any attachments are to the best of my knowledge and belief true, correct, and complete. Authorized person Paid preparer use only
Signature of authorized person E-mail address of authorized person Telephone number ( ) Address City Official title Date ID number State Date ZIP code

Firm's name (or yours if self-employed) Signature of individual preparing this return E-mail address of individual preparing this return

See instructions for where to file.

47501080094

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CT-33-D (8/08)

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47502080094