Form Rct-121 - Gross Premiums Tax Report Insurance Companies, Associations Or Exchanges -Commonwealth Of Pennsylvania Page 4

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Page 4
SETTLEMENT COMPUTATION
PENNSYLVANIA GROSS PREMIUMS TAX REPORT
RECEIVED
DLN
ACCOUNT ID
TAX PERIOD ENDING
MAILED
MAILING INSTRUCTIONS
(TO BE TYPED IN BY TAXPAYER)
MAIL SETTLEMENT ON ACCOUNT OF THIS REPORT TO:
NAME
STREET
(CITY)
(STATE)
(ZIP CODE)
DO NOT WRITE BELOW THIS LINE
SETTLEMENT – GROSS PREMIUMS TAX
(Official)
o
TYPE OF TAX
60
WHITE
o
OTHER
SELF ASSESSED TAX
Tax on PREMIUMS for the period ended December 31, 19
___________
2% TAX DEBIT OR CREDIT
Total Taxable Premiums $________________________ @ 2% $
RETALIATORY DEBIT OR CREDIT
Retaliatory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
.
T
TOTAL TAX AND RETALIATORY
Total Tax and Retaliatory Due
$
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
PENALTY DEBIT
260
Penalty (for failure to file report within time limit prescribed by law)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DEPARTMENT OF REVENUE
DEPARTMENT OF AUDITOR GENERAL
HARRISBURG, PA ___________________________________ 19 __________
HARRISBURG, PA ________________________________ 19 __________
SETTLED AND DELIVERED TO AUDITOR GENERAL:
AUDITED AND APPROVED:
(FOR THE SECRETARY OF REVENUE)
(FOR THE AUDITOR GENERAL)

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