Form Rct-143 -Mutual Thrift Institutions Net Income Tax Report - Commonwealth Of Pennsylvania
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RCT-143 (12-06)
(Department Use Only)
DLN
ACCOUNT ID
(CORPORATE BOX NUMBER)
_
Commonwealth of Pennsylvania
PA DEPARTMENT OF REVENUE
(Department Use Only)
MUTUAL THRIFT INSTITUTIONS
PO BOX 280407
Date Received
NET INCOME TAX REPORT
HARRISBURG, PA 17128-0407
FEDERAL ID (EIN)
_
NAME
MAKE ADDRESS CHANGES IN SPACE BELOW
ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
First Report
Amended Report (See instructions)
KOZ/KOEZ Credit
Last Report (See instructions)
ANNUAL PAYMENTS
TAX PERIOD ENDING
DUE DATE
✔
Check applicable block and fill in corresponding self-assessed tax, prepayments, remittance amount and Grand Totals.
REVENUE USE ONLY
B. Estimated
A. Tax Liability
C. Restricted
Remittance
Payments & Credits
✔
T/C 01-15 TAX TYPE
from Tax Report
Credit
A minus B minus C
TYPE
BUDGET
on Deposit
CODE
CODE
State S&L or Savings Bank
50
126104
Federal S&L or Savings Bank
50
126105
GRAND TOTALS
PLEASE CHECK THIS BLOCK ONLY IF THE TOTAL PAYMENT SHOWN ABOVE HAS BEEN (OR WILL BE) PAID BY ELECTRONIC FUNDS TRANSFER (EFT).
OVERPAYMENT INSTRUCTIONS
(CHECK ONLY ONE BOX)
A.
Automatically transfer overpayments to other current tax period underpaid taxes and the remaining portion of the overpayment(s) to the next tax period.
B.
Automatically transfer $
of the current tax period overpayment(s) to the next tax period after paying any other current tax period
underpaid taxes and refund the remaining portion of the current tax period overpayment(s).
C.
.
Refund the overpayment(s) of the current tax period after paying any other current tax period underpaid taxes
I hereby affirm under penalties prescribed by law that this report (including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is a true,
correct and complete report. If prepared by a person other than the taxpayer, his declaration is based on all information of which he has any knowledge.
Signature of Officer of Company
Title
Date
Telephone Number
(
)
PRINT Individual Preparer or Firm’s Name
Signature of Preparer
PRINT Individual or Firm’s Street Address
Title
Telephone Number
City
State
ZIP Code
E-mail Address
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