Fillable Form Tc-420a - Self Insurer'S Tax Return printable pdf download

Form Tc-420a - Self Insurer'S Tax Return

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Utah State Tax Commission

210 North 1950 West • Salt Lake City, UT 84134 •

TC-420A

Self Insurer’s Tax Return

Rev. 12/06

Schedule A: Report of Payroll

Taxpayer: ____________ __ ___ ___

FEIN: __ _ __ _ __ _ __ _

Period: __ _ _ __ _ __ _ __

Class Code Information

Payroll (whole dollars)

Calculation of Premiums

A. Class

D. Excluded Payroll

G. Standard Premium

B. Name of Classification

C. Total Payroll

E. Net Payroll

F. Rate

Number

(attach detail)

(Column E x Column F)

1. Total standard premium

(add column G).......................................................................................................................

2. Experience modifier — minimum rate is 0.5

(attach certification) .........................................................................

3. Adjusted premium after modifier

(line 1 x line 2)........................................................................................................

4. Safety factor

.......................................................................................................................................................................

5. Taxable Premium

(line 3 x line 4) ..................................................................................................................................

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