Form Rct-123 - Gross Premium Tax Surplus Lines Agents

Form Rct-123 - Gross Premium Tax Surplus Lines Agents - 2011 Page 2

RCT-123

(I)

Page 2

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A. SEE INSTRUCTIONS – BRANCH OFFICES

B. REVISED SCHEDULE

Amount reported on

Month

Revised

Multiple

Monthly 1620 Report

January

February

March

April

May

June

July

August

September

October

November

December

Total

Taxpayers are required to provide copies of all Monthly 1620 Reports filed with the Pennsylvania Surplus Lines Association during this year.

For each month, enter the total premiums reported on the Monthly 1620 Report filed for that month. If the Monthly 1620 Report for a month has been revised,

enter the total premiums from the revised report and place an “X” in the “Revised” column for that month.

In cases where the premiums for a month represent a combination of multiple filings with the Pennsylvania Surplus Lines Association, place an “X” in the “Multiple”

column for that month.

Enter the total premiums for this year on the “Total” line and on Line 1 below.

1. Total of Gross Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

2. Less: Total of Net Premiums returned on cancelled policies (Attach schedule; see instructions.) . . . . . . . . . . . . . . . . . . . $

3. Less: Tax exempt premiums (Attach schedule; see instructions.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

4. Gross Premiums Taxable (Line 1 less Line 2 less Line 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

➧

5. Tax at Rate of 3 percent of Gross Premiums Taxable (Line 4 X 0.03); enter this amount on Page 1, . . . . . . . . . . . . . . . . $

Column A. (whole dollars only)

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