Form Rct-122 - Gross Premiums Tax - Premiums Paid To Unauthorized Foreign Insurance Companies Page 2

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1220012205
Revenue ID
RCT-122
(09-14)
PAGE 2 OF 3
CALCULATION OF TAX
USE WHOLE DOLLARS ONLY
Life Insurance and Annuities
1.
Total Gross Premiums on Life Insurance and Annuities (Schedule A)
1.
2.
Total of Net Premiums returned on cancelled policies of
2.
Life Insurance and Annuities
3.
Taxable Gross Premiums on Life Insurance and Annuities (Line 1 minus Line 2)
3.
4.
Tax on Taxable Gross Premiums on Life Insurance and Annuities
4.
(Line 3 times tax rate – See Instructions)
All Other Types of Insurance (Other Than Life Insurance and Annuities)
5.
Total Gross Premiums on all other types of Insurance, (Schedule B)
5.
6.
Total of Net Premiums returned on cancelled policies of all other types
6.
of insurance
7.
Taxable Gross Premiums on all other types of insurance (Line 5 minus Line 6)
7.
8.
Tax on Taxable Gross Premiums on all other types of insurance
8.
(Line 7 times tax rate – See Instructions)
9.
Total Tax (Line 4 plus Line 8)
9.
1220012205
Preparer’s Information:
Firm Name
Individual Preparer Name
Firm FEIN
Phone
Address
Email
City
Social Security Number
or PTIN
State
ZIP
I affirm under penalties prescribed by law this report, including any accompanying schedules and statements, has been prepared by me and to the best of my
knowledge and belief is a true, correct and complete report.
Signature of Preparer
Date
Signature of Preparer – Please sign after printing
Reset Entire Form
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