Form Rct-123 - Gross Premiums Tax Surplus Lines Agents Page 2

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1230014205
Revenue ID
RCT-123
PAGE 2 OF 3
(08-14)
CALCULATION OF TAX
PSLA 4-Digit Customer ID Number
USE WHOLE DOLLARS ONLY
1.
Total of Taxable Premiums (from Schedule A, below)
1.
2.
Total Tax (Line 1 times tax rate - See Instructions)
2.
Schedule A
Taxable Premiums
Amount Reported on
Revised
Multiple
Monthly 1620 Report
January
February
March
April
May
June
July
August
September
October
November
December
Total
If Filing for Several Branch Offices Complete Schedule B - Page 3
Taxpayers are required to provide copies of all monthly 1620 reports filed with the
Pennsylvania Surplus Lines Association during this tax year.
1230014205
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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