Form Rct-121-C - Gross Premium Tax - Pennsylvania Department Of Revenue - 2009

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RCT-121-C (01-10) (I)
1213009101
GROSS PREMIUM TAX
(Department Use Only)
FOR FOREIGN CASUALTY OR FOREIGN FIRE
DLN
Bureau of Corporation Taxes
INSURANCE COMPANIES, ASSOCIATIONS OR EXCHANGES
PO BOX 280407
2009 REPORT
Harrisburg PA 17128-0407
ACCOUNT ID
(CORPORATE BOX NUMBER)
_
NAME
(Department Use Only)
Date Received
ADDRESS
FEDERAL ID (EIN)
_
CITY
STATE
ZIP CODE
Check to indicate a change of address
Check to send all correspondence to preparer.
State of Domicile
NAIC No.
First Report
Amended Report (See instructions.)
EIP Credit
Last Report (Out-of-Existence as of ___________________.)
ANNUAL PAYMENTS
TAX PERIOD ENDING
DUE DATE
12/31/09
04/15/10
Check tax type for which company is registered with the insurance department, and fill in corresponding self-assessed tax, prepayment, remit-

tance amounts and grand totals.
B. Estimated
REVENUE USE ONLY
A. Tax Liability
C. Restricted
Remittance

T/C 01-15 TAX TYPE
Payments & Credits
TYPE
BUDGET
from Tax Report
Credit
A minus B minus C
on Deposit
CODE
CODE
FOREIGN CASUALTY - 2%
60
710101
FOREIGN CASUALTY - RETALIATORY
60
125163
FOREIGN FIRE - 2%
60
115101
FOREIGN FIRE - RETALIATORY
60
125165
GRAND TOTALS
PLEASE CHECK THIS BOX ONLY IF YOU ARE CLAIMING A PIGA AND/OR A GUARANTEE CREDIT.
PLEASE CHECK THIS BOX ONLY IF THE TOTAL PAYMENT SHOWN ABOVE HAS BEEN OR WILL BE PAID BY ELECTRONIC FUNDS TRANSFER (EFT).
OVERPAYMENT INSTRUCTIONS
(Choose only Option A or Option B and write the appropriate letter in the box provided.)
A = Automatically transfer overpayments to other current-tax-period underpaid taxes, then to the next tax period.
B = Refund overpayment(s) of the current-tax-period after paying any other current-tax-period underpaid taxes.
By checking the “Amended Report” box on this form, the taxpayer consents to the extension of the assessment period for this tax year to one year from the date of filing of this amended report
or three years from the filing of the original report, whichever period last expires. For purposes of this extension, an original report filed before the due date is deemed filed on the due date.
I affirm under penalties prescribed by law that this report (including any accompanying schedules and statements) was examined by me, to the best of my knowledge and belief is a true, cor-
rect and complete report and I am authorized to execute this consent to the extension of the assessment period. This declaration is based on all information of which I have any knowledge.
Signature of Officer of Company
Title
Date
Telephone Number
(
)
PRINT Individual Preparer or Firm’s Name
Signature of Preparer
Fax Number
(
)
PRINT Individual or Firm’s Street Address
Title
Telephone Number
(
)
City
State
ZIP Code
E-mail Address
1213009101
1213009101

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