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Insurance Premium Return Payment (M11, M11L and M11T ilers) PV42
IMPORTANT: Type in the required information while this form is on the screen and print a copy. A personalized scan
line will be printed on the voucher using the information you entered. To help ensure your payment is properly credited
to your account, verify that the tax-year end date and Minnesota tax ID number are included in the scan line.
When you print this voucher, be sure to set the Page Scaling to “None” in your Print options. DO NOT check the “Auto-
rotate and center pages” or “Shrink to it” boxes. If they are already checked, click on the box to uncheck them.
Due date is March 1 • If you don’t have Internet access, you can ment services). To use this service, you will
When the due date falls on a Saturday, pay by phone at 1-800-570-3329. be charged a fee that goes directly to Official
Payments Corporation. The Department of
Sunday or legal holiday, payments elec- For both methods, you’ll need your Minne-
Revenue does not have any financial agree-
tronically made or postmarked on the next sota tax ID number, password and banking
ment with Official Payments and does not
business day are considered on time. information. Note: If you’re using the e-File
receive any of its fees.
Minnesota system for the first time and
Before you can make a you need a temporary password, call our To pay by credit card:
payment Registration Services office at 651-282-5225 • go to oficialpayments.com, or
To ensure your payment is processed cor- or 1-800-657-3605. • call 1-800-272-9829.
rectly, you must have a Minnesota tax ID After you authorize the payment, you’ll re-
number. To register, go to our website at ceive a confirmation number. You can can- Pay by check
www.taxes.state.mn.us and click “Register cel a payment up to one business day before If you are not required to pay electroni-
for a Minnesota tax ID number” on the the scheduled payment date, if needed. cally, you may pay by check. Complete the
e-Services menu. If you don’t have Inter- voucher below and mail it with your check.
net access, you can register by phone at Do not send in the voucher below unless All information is required to process your
651-282-5225 or 1-800-657-3605. you are paying by check. payment, including your Minnesota tax ID
number.
Pay electronically Pay by credit card When you pay by check, your check autho-
• To pay over the Internet, go to our For a fee, you can pay your Minnesota busi-
rizes us to make a one-time electronic fund
website at www.taxes.state.mn.us and ness taxes by credit card through Official
transfer from your account, and you may
click “Login to e-File Minnesota” on the Payments Corporation (a national company
not receive your canceled check.
e-Services menu. Follow the prompts for that partners with federal, state and local
a business to make an insurance premium governments to provide credit card pay-
return payment.
(Rev. 12/09) Cut carefully along this line to detach.
PV42 076
Insurance Premium Return Payment Minnesota tax ID
(required)
Name of insurance company
Address
NAIC number
City State Zip code Enter the last day of your tax year.
Period end date Use mmddyy format. Example: If your u
(mmddyy) tax year ends 12/31/09, enter 123109.
AMOUNT
Make check payable to Minnesota Revenue and mail with your return. OF CHECK
00
t To help ensure your payment is properly credited to your account, be sure to verify that the scan line below includes the correct period end date and your Minnesota tax ID.
0760200000000000000000123110000000000000 0000000000000000000000000
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