State of Rhode Island Division of Taxation 
        Form IT-95 
        Informational Return of Insurance Companies                                                                 16160599990101

Decedent's first name                                  MI     Last name                                             Suffix Decedent's social security number

Decedent's address - Legal residence (domicile) at time of death                          City, town or post office               State    ZIP code

Insurance company information     Name:

                                                        Address:

Date of death

Type of contract

Name(s) of payee

Amount of proceeds if payable in 
one sum
Value of proceeds if not paid in 
one sum

Provisions of policy with respect 
to the deferred payments or  
installments

Owner of policy if not the insured

                                                                 INSTRUCTIONS: 
                                                                                           
This form must be filed with the Rhode Island Division of Taxation within thirty (30) days of receipt of information 
        of the death of the insured where the payments made or to be made exceed fifity thousand ($50,000) dollars. 
                                                                                           
                  A SEPARATE STATEMENT MUST BE FILED FOR EACH INSURANCE CONTRACT

        The undersigned officer of the above named insurance company hereby certifies that this statement is true and correct.
Auothorized signature                                           Print name                                    Date         Telephone number

Address                                                         City, town or post office  State           ZIP Code                    PTIN

                                  Mail to RI Division of Taxation - One Capitol Hill - Providence, RI 02908

                                                                                                                                           Revised 10/2020