Number, street, and room or suite no. (If a P.O. box, see page 5 of instructions.) C Date incorporated

Transcription

1 Form 0-L Department of the Treasury Internal Revenue Servie A Inome Dedutions (See instrutions for limitations on dedutions.) Tax and Payments (See page of instrutions) Chek if: () Consolidated return (attah Form ) () Nonlife insurane ompanies are inluded U.S. Life Insurane Company Inome Tax Return For alendar year or tax year eginning,, ending, Instrutions are separate. See page for Paperwork Redution At Notie. Please print or type Name Gross premiums, et., less return premiums, et. Enter alane Net derease, if any, in reserves (see page of instrutions) 0% of any derease in reserves under setion 0(f)()(B)(ii) % of yearend alane of reserves under setion 0(e)()(B) Investment inome (Shedule B, line ) (see page of instrutions) Net apital gain (Shedule D, line (Form 0)) Inome from a speial loss disount aount (attah Form ) Other inome (attah shedule) Life insurane ompany gross inome. Add lines through 0 Death enefits, et. 0 Net inrease, if any, in reserves (Shedule F, line ) 0% of any inrease in reserves under setion 0(f)()(B)(i) Dedutile poliyholder dividends (Shedule E, line ) Consideration paid for assumption y another person of liailities Dividends reimursale y taxpayer a Interest Less tax-exempt interest expense Bal Dedutile poliy aquisition expenses (Shedule G, line 0) Additional dedution (attah Form ) Other dedutions (see instrutions) (attah shedule) 0 Dividends-reeived dedution (Shedule A, line, olumn ()) 0 Operations loss dedution (see page of instrutions) (attah shedule) Total dedutions. Add lines 0 through Gain or (loss) from operations. Sutrat line from line Small life insurane ompany dedution (Shedule H, line ) Life insurane ompany taxale inome (LICTI). Sutrat line from line Limitation on noninsurane losses (Shedule I, line ) Amount sutrated from poliyholders surplus aount (Shedule J, Part II, line 0) B OMB No. -0 Employer identifiation numer Numer, street, and room or suite no. (If a P.O. ox, see page of instrutions.) C Date inorporated City or town, state, and ZIP ode D Chek appliale ox if an eletion has een made under setion(s) E Chek if: () Final return () Change of address () Amended return ()()(C) Total taxale inome. Add lines,, and ; however, the total may not e less than line Total tax (Shedule K, line 0) 0a overpayment redited to 0a Prior year(s) speial estimated tax payments to e applied 0 estimated tax payments 0 d speial estimated tax payments (Do not inlude on line 0f) 0d e refund applied for on Form 0e ( ) 0f g Tax deposited with Form 00 0g h Credit from regulated investment ompanies (attah Form ) 0h i Credit for Federal tax on fuels (attah Form ) 0i j U.S. inome tax paid or withheld at soure (attah Form 0-S) 0j 0k Estimated tax penalty. Chek if Form 0 is attahed TAX DUE. If line 0k is smaller than the total of lines and, enter AMOUNT OWED OVERPAYMENT. If line 0k is larger than the total of lines and, enter AMOUNT OVERPAID Enter amount of line you want: Credited to estimated tax $ Refunded Under penalties of perjury, I delare that I have examined this return, inluding aompanying shedules and statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Delaration of preparer (other than taxpayer) is ased on all information of whih the preparer has any knowledge. Please Sign Here Paid Preparer s Use Only Signature of offier Preparer s signature Firm s name (or yours if self-employed) and address Cat. No. 0E Date Date Title Chek if selfemployed EIN ZIP Code (d) Preparer s soial seurity no.

2 Form 0-L () SCHEDULE A Total dedutions. Add lines and, olumn (). Redue the dedution as provided in setion 0(a)()(D)(ii). Enter here and on page, line 0 and on Shedule J, Part I, line SCHEDULE B Gross Investment Inome (Setion (d)) (See page 0 of instrutions.) Interest (exluding tax-exempt interest) Gross taxale dividends (Shedule A, line, olumn (a)) Gross rents Gross royalties Leases, terminations, et. Exess of net short-term apital gain over net long-term apital loss (Shedule D, line (Form 0)) Gross inome from trade or usiness other than insurane (attah shedule) Investment inome. Add lines through. Enter here and on page, line Tax-exempt interest. Enter here and on Shedule F, line, and Shedule J, Part I, line d 0 Add lines and 0 00% qualifying dividends Gross investment inome. Sutrat line from line 0. Enter here and on Shedule F, line SCHEDULE C Differential Earnings Amount (Mutual ompanies only) (Setion 0) (See page of instrutions.) Annual statement surplus and apital Nonadmitted finanial assets (attah shedule) Exess of statutory reserves over tax reserves on setion 0() items Defiieny reserves a Asset valuation reserve Interest maintenane reserve Other voluntary reserves 0% of the amount of any provision for poliyholder dividends payale in the next tax year a Add lines through Dividend Inome and Dividends-Reeived Dedution (See page of instrutions.) Dividends sujet to proration (a) Dividends reeived () % Domesti orporations, less-than-0%-owned (other than detfinaned stok) 0 Domesti orporations, 0%-or-more-owned (other than detfinaned stok) 0 Det-finaned stok of domesti and foreign orporations see instrutions Puli utility orporations, less-than-0%-owned Puli utility orporations, 0%-or-more-owned Foreign orporations, less-than-0%-owned, and ertain FSCs 0 Foreign orporations, 0%-or-more-owned, and ertain FSCs 0 Wholly owned foreign susidiaries (setion ()) 00 Certain affiliated ompany dividends 00 0 Gross dividends-reeived dedution. Add lines through 0 Company share perentage (Shedule F, line ) Prorated amount. Line 0 times line Dividends not sujet to proration Affiliated ompany dividends see instrutions Other orporate dividends Total dividends. Add lines through, olumn (a). Enter here and on Shedule B, line Adjustment for equity alloale to nonontiguous Western Hemisphere ountries and other adjustments Comine lines a and, oth olumns Total of line, olumns (a) and () 0 Tentative average equity ase Enter 0% of line Other adjustments (attah shedule) Average equity ase. Add lines 0 and Differential earnings amount (line times the differential earnings rate). Enter here and on Shedule E, line a a 0 (a) End of preeding tax year () Dedution ((a) times ()) () End of this tax year Page

3 Form 0-L () Page SCHEDULE E Poliyholder Dividends (Setion 0) (See page of instrutions.) Amounts paid or arued Exess interest Premium adjustments Experiene-rated refunds Add lines through Differential earnings amount for mutual ompanies only (Shedule C, line ) Dedutile poliyholder dividends. Sutrat line from line. If zero or less, enter -0-. Enter here and on page, line, and on Shedule F, line Adjustment to reserves of mutual insurane ompany (exess of line over line ). Enter here and on Shedule F, line Dedutile perentage. Divide line y line % SCHEDULE F Inrease (Derease) in Reserves (Setion 0) and Company/Poliyholder Share Perentage (Setion ) (See page of instrutions.) (a) Beginning of tax year Life insurane reserves Unearned premiums and unpaid losses Supplementary ontrats Dividend aumulations and other amounts Advane premiums Speial ontingeny reserves Add lines through Inrease (derease) in reserves under setion 0. Sutrat line, olumn (a) from line, olumn () 0a f 0 d 0 e Gross investment inome (Shedule B, line ) Required interest on reserves under setions 0()(), (), (), (), and () (attah shedule) Dedutile exess interest (Shedule E, line, times Shedule E, line ). Enter here and on line elow Dedutile amounts redited to employee pension funds Dedutile amounts redited to deferred annuities Dedutile interest on amounts left on deposit Total poliy interest. Add lines 0a through 0e. Enter here and on line elow Sutrat line 0f from line Life insurane ompany gross inome (enter amount from page, line ) Tax-exempt interest (Shedule B, line ) Add lines and Inrease in reserves from line aove. (If a derease in reserves, enter -0-.) Sutrat line from line Investment inome ratio. Divide line y line Dedutile poliyholder dividends (Shedule E, line ) Dedutile exess interest from line 0 aove Dedutile dividends on employee pension funds Dedutile dividends on deferred annuities Dedutile premium and mortality harges for ontrats paying exess interest Add lines through Sutrat line from line Investment portion of dividends. Line times line Poliy interest from line 0f aove Poliyholder share amount. Add lines and Net investment inome (see page of instrutions) Poliyholder share amount from line aove Company share of net investment inome. Sutrat line from line Total share perentage Company share perentage. Divide line 0 y line. Enter here and on Shedule A, line Poliyholders share perentage. Sutrat line from line Poliyholders share of tax-exempt interest. Multiply line aove y line Sutrat line from line Adjustment to reserves of mutual insurane ompany per setion 0(a)() (Shedule E, line ) Net inrease (derease) in reserves. Sutrat line from line. If an inrease, enter here and on page, line. If a (derease), enter here and on page, line 0 0a 0 0 0d 0e 0f 0 () End of tax year 00% % %

4 Form 0-L () SCHEDULE G Poliy Aquisition Expenses (Setion ) (See page of instrutions.) (a) Annuity () Group life insurane () Other Page Gross premiums and other onsideration Return premiums and premiums and other onsideration inurred for reinsurane Net premiums. Sutrat line from line Net premium perentage.%.0%.% Multiply line y line Add line, olumns (a), (), and (), and enter here. If zero or less, enter -0- on lines and Unused alane of negative apitalization amount from prior years ( ) Comine lines and. If zero or less, enter -0- General dedutions (attah shedule) 0 Enter the lesser of line or line 0 Dedutile general dedutions. Sutrat line 0 from line. Enter here and inlude on page, line If the amount on line is negative, enter it as a positive amount. If the amount on line is positive, enter -0- Unamortized speified poliy aquisition expenses from prior years dedutile in the urrent year Dedutile negative apitalization amount. Enter the lesser of line or line a Tentative 0 month speified poliy aquisition expenses. Enter amount from line 0, ut not more than $ million a Limitation $0,000,000 Phase-out amount. Sutrat line from line 0. If zero or less, enter -0- a Current year 0-month speified poliy aquisiton expenses. Sutrat line from line a. If zero or less, enter -0- a Enter 0% of line a a Current year 0-month speified poliy aquisition expenses. Sutrat line a from line 0 a Enter % of line a Enter the appliale amount of amortization from speified poliy aquisition expenses apitalized in prior years and dedutile this year. Attah shedule 0 Dedutile poliy aquisition expenses. Add lines,,, and. Enter here and on page, line 0

5 Form 0-L () Page SCHEDULE H Small Life Insurane Company Dedution (Setion 0(a)) If total assets (Shedule L, line, olumn ()), are $00 million or more, omplete lines through, line, and enter -0- on line. (See page of instrutions.) Company Part I Controlled Group Information Tentative LICTI (a) Inome () (Loss) Add lines through in oth olumns Net ontrolled group tentative LICTI. Sutrat line, olumn () from line, olumn (a). Enter here and on line elow Part II Small Life Insurane Company Dedution Gain or (loss) from operations from page, line a Noninsurane inome a Noninsurane dedutions 0a Gain or (loss) on insurane operations. Sutrat line a from line and add line 0a Adjustments (attah shedule) 0 Tentative LICTI. Comine lines 0a and 0 0 Net ontrolled group tentative LICTI from line aove Comined tentative LICTI. Add line 0 and line. If $ million or more, skip lines through and enter -0- on line elow and on page, line Enter 0% of line, ut not more than $,00,000 a Maximum statutory amount a $,000,000 Sutrat line a from line. If zero or less, enter -0- Enter % of line, ut not more than $,00,000 Tentative small life insurane ompany dedution. Sutrat line from line Taxpayer s share. Divide line 0 y the total of line, olumn (a) and line 0. If line 0 is zero or less, enter -0- on this line Small life insurane ompany dedution. Multiply line y line. Enter here and on page, line, and on Shedule J, Part I, line Limitation on Noninsurane Losses (Setion 0()()(C)) (See page of instrutions.) SCHEDULE I Noninsurane inome (attah shedule) Noninsurane dedutions (attah shedule) Noninsurane operations loss dedutions Add lines and Noninsurane loss. Sutrat line from line. If line is greater than line, skip lines through and enter -0- on line Enter % of line Enter % of the exess of LICTI (page, line ) over any noninsurane loss inluded on page Enter the lesser of line or line Limitation on noninsurane losses. Sutrat line from line. Enter here and on page, line

6 Form 0-L () Page SCHEDULE J Part I Shareholders Surplus Aount (Setion ()) (See page of instrutions.) (Stok Companies Only) a Balane at the eginning of the tax year Transfers under pre- setions (d)() and () for the preeding year Balane at the eginning of the tax year. Add lines a and a LICTI. Add lines and, page. If zero or less, enter -0- Small life insurane ompany dedution (Shedule H, line ) Dividends-reeived dedution (Shedule A, line, olumn ()) d Tax-exempt interest (Shedule B, line ) Add lines through d Tax liaility without regard to setion. Figure the tax on line a as if it were total taxale inome Sutrat line from line. If zero or less, enter -0- Diret or indiret distriutions in the tax year ut not more than line a a d Balane at the end of the tax year. Sutrat line from line Part II Poliyholders Surplus Aount (Setion (d)) (See page of instrutions.) (Stok Companies Only) a d e Balane at the eginning of the tax year Diret or indiret distriutions in exess of the amount on line, Part I aove Tax inrease on line a Sutrations from aount under pre- setions (d)() and () Tax inrease on line Sutration from aount under pre- setion (d)() a d e 0 Add lines a through e, ut not more than line. Enter here and on page, line 0 Balane at the end of the tax year. Sutrat line 0 from line SCHEDULE K Tax Computation (See page of instrutions.) Chek if the orporation is a memer of a ontrolled group (see setions and ) a Enter the orporation s share of the $0,000, $,000, and $,,000 taxale inome raket amounts (in that order): () $ () $ () $ Enter the orporation s share of: () additional % tax (not more than $,0) $ () additional % tax (not more than $00,000) $ Inome tax a Foreign tax redit (attah Form ) a Other redits Important: Memers of a ontrolled group, see instrutions on page. If the ox on line is heked: General usiness redit. Enter here and hek whih forms are attahed: d Credit for prior year minimum tax (attah Form ) d Total redits. Add lines a through d Sutrat line from line Foreign orporations tax on inome not effetively onneted with U.S. usiness Reapture taxes. Chek if from: Form Form Alternative minimum tax (attah Form ) 0 Total tax. Add lines through. Enter here and on page, line 0

7 Form 0-L () Page SCHEDULE L Part I Total Assets (Setion 0(a)()(C)) (See page of instrutions.) (a) Beginning of tax year () Close of tax year Real property Stoks Proportionate share of partnership and trust assets Other assets (attah shedule) Total assets of ontrolled groups Total assets. Add lines through SCHEDULE L Part II Total Assets and Total Insurane Liailities (Setion ()()(B)(i)) (See page of instrutions.) Line referenes elow are to the Assets (lines and ) and Liailities, Surplus, and Other Funds (lines through ) Setions of the NAIC Annual Statement. (a) Beginning of tax year () Close of tax year Sutotals for assets (line ) Total assets (line ) Reserve for life poliies and ontrats (line ) Reserve for aident and health poliies (line ) Supplementary ontrats without life ontingenies (line ) Life poliy and ontrat laims (line.) Aident and health poliy and ontrat laims (line.) Poliyholder s dividend and oupon aumulations (line ) Premiums and annuity onsiderations reeived in advane less disount (line ) 0 Poliyholder premiums (line 0.) Guaranteed interest ontrats (line 0.) Other ontrat deposit funds (line 0.) Surrender values on aneled poliies (line.) Part of other amounts payale on reinsurane assumed (line.) 0 Part of aggregate write-ins for liailities (line ). (Only inlude items or amounts inludale in total insurane liailities on U.S. usiness as defined in setion ()()(B)(i)) Separate aounts statement (line ) Total insurane liailities. Add lines through

8 Form 0-L () SCHEDULE M Other Information (See page of instrutions.) Chek method of aounting: Yes No If Yes, a Arual Other (speify) a Enter perentage owned Chek if the orporation is a: Enter owner s ountry a Legal reserve ompany if heked: Kind of ompany: The orporation may have to file Form. () Stok () Mutual Enter numer of Forms attahed Prinipal usiness: () Life insurane Was the orporation a U.S. shareholder of any () Health and aident insurane ontrolled foreign orporation? (See setions Fraternal or assessment assoiation and.) Burial or other insurane ompany If Yes, attah Form for eah suh orporation. Enter the perentage that the total of the orporation s life insurane reserves (setion ()) plus unearned premiums and unpaid losses (whether or not asertained) on nonanelale life, health or aident poliies not inluded in life insurane reserves ears to the orporation s total reserves (setion ()) %. Attah a shedule of the omputation. Does the orporation have any variale annuity ontrats outstanding? Did the orporation at the end of the tax year own, diretly or indiretly, 0% or more of the voting stok of a domesti orporation? (For rules of attriution, see setion ().) If Yes, attah a shedule showing (a) name and identifying numer, () perentage owned, and () taxale inome or (loss) efore NOL and speial dedutions of suh orporation for the tax year ending with or within your tax year. Is the orporation a susidiary in an affiliated group or a parent-susidiary ontrolled group? a If Yes, enter employer identifiation numer and name of the parent orporation. Did any individual, partnership, orporation, estate, or trust at the end of the tax year own, diretly or indiretly, 0% or more of the orporation s voting stok? (For rules of attriution, see setion ().) If Yes, omplete a and elow Attah a shedule showing name and identifying numer. (Do not inlude any information already entered in aove.) Enter perentage owned Did one foreign person at any time during the tax year own, diretly or indiretly, at least % of (a) the total voting power of all lasses of stok of the orporation entitled to vote or () the total value of all lasses of stok of the orporation? 0 a Enter numer of Forms attahed At any time during the alendar year, did the orporation have an interest in or a signature or other authority over a finanial aount in a foreign ountry (suh as a ank, seurities, or other finanial aount)? If Yes, the orporation may have to file Form TD F 0-..) If Yes, enter the name of the foreign ountry. During the tax year, did the orporation reeive a distriution from, or was it the grantor of, or transferor to, a foreign trust? If Yes, see page of the instrutions for other forms the orporation may have to file. Has the orporation eleted to use its own payout pattern for disounting unpaid losses and unpaid loss adjustment expenses? Does the orporation disount any of the loss reserves shown on its annual statement? Enter the total unpaid losses shown on the orporation s annual statement: () For the urrent year: $ () For the previous year: $ Enter the total unpaid loss adjustment expenses shown on the orporation s annual statement: () For the urrent year: $ () For the previous year: $ If the orporation has a loss from operations for the tax year and is eleting under setion 0()() to forego the arryak period, hek here Enter the availale OLD arryover from prior tax years. (Do not redue it y any dedution on page, line.) $ Yes Page No