Form Rct-121-C - Gross Premium Tax For Foreign Casualty Or Foreign Fire Insurance Companies, Associations Or Exchanges - 2011
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3RCT-121-C (11-11) (I)
1213011101
GROSS PREMIUM TAX
FOR FOREIGN CASUALTY OR FOREIGN FIRE
Bureau of Corporation Taxes
INSURANCE COMPANIES, ASSOCIATIONS OR EXCHANGES
PO BOX 280407
2011 REPORT
Harrisburg PA 17128-0407
CORP TAX ACCOUNT ID
_
NAME
(Department Use Only)
Date Received
ADDRESS
FEDERAL ID (EIN)
_
CITY
STATE
ZIP CODE
o
o
Check to send all correspondence to preparer.
Check to indicate a change of address
State of Domicile
NAIC No.
o
o
o
o
First Report
Amended Report (See instructions.)
EIP Credit
Last Report (Out-of-Existence as of ___________________.)
ANNUAL PAYMENTS
TAX YEAR ENDING
DUE DATE
12/31/11
04/15/12
Fill in corresponding self-assessed tax, prepayments, restricted credit, remittance amount and grand totals.
B. Estimated
REVENUE USE ONLY
A. Tax Liability
C. Restricted
Remittance
TAX TYPE
Payments & Credits
from Tax Report
Credit
A minus B minus C
TYPE
BUDGET
on Deposit
CODE
CODE
FOREIGN CASUALTY - 2%
60
710101
FOREIGN CASUALTY - RETALIATORY
60
125163
FOREIGN FIRE - 2%
60
115101
FOREIGN FIRE - RETALIATORY
60
125165
GRAND TOTALS
o
PLEASE CHECK THIS BOX ONLY IF THE TOTAL PAYMENT SHOWN ABOVE HAS BEEN OR WILL BE PAID ELECTRONICALLY.
OVERPAYMENT INSTRUCTIONS
(Choose only Option A or Option B and write the appropriate letter in the box provided.)
o
A = Automatically transfer overpayments to other underpaid taxes for the current tax period, then to the next tax period.
B = Refund overpayment(s) of the current tax period after paying any other underpaid taxes for the current tax period.
By checking the “Amended Report” box on this form, the taxpayer consents to the extension of the assessment period for this tax year to one year from the date of filing of this amended report
or three years from the filing of the original report, whichever period last expires. For purposes of this extension, an original report filed before the due date is deemed filed on the due date.
I affirm under penalties prescribed by law that this report (including any accompanying schedules and statements) was examined by me, to the best of my knowledge and belief is a true, cor-
rect and complete report and I am authorized to execute this consent to the extension of the assessment period. This declaration is based on all information of which I have any knowledge.
Signature of Officer
Title
Date
Telephone Number
(
)
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.
PRINT Individual Preparer or Firm’s Name
Signature of Preparer
Fax Number
(
)
PRINT Individual or Firm’s Street Address
Title
Telephone Number
(
)
City
State
ZIP Code
E-mail Address
1213011101
1213011101
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