General Information For Rct-121a Page 2

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General Information for RCT-121A
RCT-121A-I (11-12)
Page 2 of 4
Correspondence to Preparer
Enter “Y” in the block on Page 1 if all correspondence (notices and requests for additional information) is to be sent to the preparer’s address.
If “Y” is entered, the address recorded on Page 2 will be used.
Amended Report
Enter “Y” in the block on Page 1 if you are filing an amended report to add, delete or adjust information. Provide documentation to support
all changes being made. An amended report should only be filed if an original report was filed previously for the same period.
An amended report must be filed within three years of the filed date of the original report. The department may adjust the tax originally
reported based on information from the amended report. The taxpayer must consent to extend the assessment period. If the amended report
is timely filed and the taxpayer consented to extend the assessment period, the time period in which to assess tax will be the greater of
three years from the filed date of the original report or one year from the filed date of the amended report.
When filing an amended report, record the amended tax liability on Page 1, Line 1a, 1b or 1c. REV-1175, Schedule AR, must be included
when filing an amended report.
First Report
Enter “Y” in the block on Page 1 if this is the taxpayer’s first PA gross premiums tax filing.
Electronic Payment
Enter “Y” in the block on Page 1 if the taxpayer has made any electronic payments using e-TIDES.
KOZ/EIP Credit
Enter “Y” in the block on Page 1 if the corporate taxpayer is claiming the Keystone Opportunity Zone Credit, the Keystone Opportunity
Expansion Zone Credit or the Employment Incentive Payment Credit. For these and all other restricted credits, complete Line 4 on Page 1.
The following credits are available against gross premiums tax:
• Neighborhood Assistance Program Tax Credit
• Educational Improvement Tax Credit
• Employment Incentive Payment Credit
° Employment incentive payment credits are not posted to the account prior to assessment, therefore the account review state-
ment will reflect a debit balance until the credit is approved. Schedule W must be attached to claim this credit. Check the appro-
priate box if the corporate taxpayer is claiming the employment incentive payment credit.
• PA Life and Health Insurance Guaranty Association Credit
° To claim a credit for a PA Life and Health Insurance Guaranty Association assessment, submit a copy of the assessment invoice
certificate of contribution for the first year the credit is claimed. Submit all pages. Include a copy of the Pennsylvania Business
Page, Schedule T for the year immediately preceding the year of the assessment and a schedule of all credits claimed for each
type of assessment (i.e. life insurance, accident and health insurance annuity). Note, this credit is only allowed for policies that
guarantee premium rates without increase.
• PA Property and Casualty Insurance Guaranty Association (PIGA) Credit
• Research Enhancement and Protection Tax Credit
Last Report
• Enter “Y” in the block on Page 1 if this report will be the last report filed with the department. Indicate the effective date of the event
as MM DD YYYY.
• Include information from the Pennsylvania Insurance Department verifying the taxpayer’s insurance license expired, was cancelled
or not renewed.
• Include a copy of the regulatory authority’s approval of the merger, dissolution, plan of reorganization and/or articles of merger.
• Provide the Revenue ID number and FEIN of the surviving entity, if applicable.
Corporate Officer Information
A corporate officer must sign and date the tax report. The signature must be original; photocopies or faxes will not be accepted. Print the
first and last name, title, Social Security number, telephone number and email address of the corporate officer.
Preparer’s Information
Paid preparers must sign and date the tax report. If the preparer works for a firm, provide the name, FEIN and address of the firm along
with the name, telephone number, email address and PTIN/SSN of the individual preparing the report. If the preparer is an individual
without any association to a firm, provide the name, address, telephone number, email address and PTIN/SSN of the individual prepar-
ing the report.
Estimated Payment Instructions
All accounts are expected to remit estimated prepayments toward the final liability a corporation estimates is due for the taxable year.
Prepayment for gross premiums tax is due March 15 of the reported year. Tax remaining due at the close of the taxable year must be
paid on or before April 15 of the following year.

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