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Utah State Tax Commission
TC-49
210 N 1950 W • SLC, UT 84134 •
Rev. 12/09
Insurance Premium Tax Return
FEIN/Account Number
Find TC-49 Instructions at this site.
Name and address (please correct any errors)
Tax Period
Start below this line. Enter your company name and address.
Return due on or before
Check, if applicable
Amended
Final Return
Round to whole dollar amounts
1. Gross tax due (amount from Schedule A, line 36 or 37, whichever is greater, but not less than zero) ................
1
00
2. Rocky Mtn Cntr / Occupational & Environmental Health (see instructions).
2
00
3. Utah based companies only. Examination fees (attach schedule)...............
3
00
INS
4. Guaranty Association credit (please note restrictions in the instructions) ...
4
00
5. Total credits (add lines 2 through 4) ............................................................
5
00
6. Allowable credits (lesser of line 1 or line 5, but not less than zero) ......................................................................
6
00
7. Previous Guaranty Association Credit Refunds (see instructions) .......................................................................
7
00
8. Total tax due (line 1 less line 6 plus line 7). If less than zero, enter "0" ................................................................
8
00
9. Prepayments
a. Guaranty Association refunds remitted .......................
9a
00
b. Refund applied from prior years..................................
9b
00
c. First quarter.................................................................
9c
00
d. Second quarter ...........................................................
9d
00
e. Third quarter ...............................................................
9e
00
10. Total prepayments (add lines 9a through 9e)........................................................................................................
10
00
11. TAX DUE WITH RETURN (if line 8 is greater than line 10, subtract line 10 from line 8 and enter amount) .........
11
00
12. OVERPAYMENT (if line 10 is greater than line 8, subtract line 8 from line 10 and enter amount) .......................
12
00
Check box at right if you want refund applied to tax for a different year................................................
Enter year:_ _ _ _ __ _
DO NOT INCLUDE UTAH STATE INSURANCE DEPARTMENT FEES WITH THIS RETURN.
I declare under the penalties provided by law that to the best of my knowledge this is a true, complete and correct return.
Authorized Signature
Date
Telephone
Return Prepared By
Date
Telephone
Return ENTIRE form, coupon and payment to the address below. Please return the original; make a copy for your records.
Refold the form so the Tax Commission address appears in the envelope window. If coupon becomes separated from the form, do not reattach.
TC-49_1.ai Rev. 12/07
INSURANCE PREMIUM TAX RETURN
– TC-49
Amount
00
Federal ID Number
Filing Period
Due Date
Paid
Make check or money order payable to the Utah State Tax Commission.
Do not send cash. Do not staple check to this coupon. Detach check stub.
Enter business name:
UTAH STATE TAX COMMISSION
INSURANCE PREMIUM TAX RETURN
210 N 1950 W
Print Form
SLC UT
84134-0130
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