Form Rct-123 - Gross Premiums Tax Report - Surplus Lines Agents
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3No dashes (-) or slashes (/) to be used in any fields, this includes Date, FEIN, Phone and ZIP
1230014105
OFFICIAL USE ONLY
RCT-123
Date Received (Official Use Only)
PAGE 1 OF 3
(08-14)
GROSS PREMIUMS TAX
SURPLUS LINES AGENTS
Tax Year Begin:
START
Revenue ID
Federal ID (FEIN)
Parent Corporation (FEIN)
12/31/20
Tax Year End:
_ _
Due Date: January 31
Taxpayer Name
Please select correct letter in drop down
Check to Indicate a Change of Address
First Line of Address
Send All Correspondence to the Preparer
Amended Report
Second Line of Address
First Report
Payment Made Electronically
City
State
ZIP
Last Report
Phone
Out of Existence as of:
Email
USE WHOLE DOLLARS ONLY
1.
Total Tax (From Page 2, Line 2)
1.
2.
Total Estimated Payments
2.
3.
Total Payments Carried Forward From Prior Year Return
3.
4.
Total “Restricted” Tax Credits
4.
5.
Total Credit: (Line 2 plus Line 3 plus Line 4)
5.
6.
Tax Due: (If Line 1 is more than Line 5, enter the difference here.)
6.
7.
Remittance: (Include interest and penalty, if applicable)
7.
8.
OVERPAYMENT: (If Line 5 is more than Line 1, enter the difference here.)
8.
9.
Refund: (Amount of Line 8 to be refunded after offsetting all unpaid liabilities)
9.
10. Transfer: (Amount of Line 8 to be credited to the next tax year after offsetting
10.
all unpaid liabilities)
1230014105
Corporate Officer Information:
Social Security
Number of Officer
Officer Last Name
Officer First Name
Phone
Title of Officer
Email
I affirm under penalties prescribed by law this report, including any accompanying schedules and statements, has been examined by me and to the best of my
knowledge and belief is a true, correct and complete report. If this report is an amended report, the taxpayer hereby 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,
and agrees to retain all required records pertaining to that tax and tax period until the end of the extended assessment period, regardless of any statutory
provision providing for a shorter period of retention. For purposes of this extension, an original report filed before the due date is deemed filed on the due date.
I am authorized to execute this consent to the extension of the assessment period.
Signature of Officer
Date
Signature of Officer – Please sign after printing
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