Form Rct-123 - Gross Premiums Tax Report - Surplus Lines Agents Page 3

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RCT-123
Revenue ID
PAGE 3 OF 3
(08-14)
GROSS PREMIUM TAX REPORT
BRANCH OFFICE SCHEDULE
EIN:
SCHEDULE B
Taxpayer Name
Total
Less Total
Less Tax
Gross
Tax Amount
Customer
Address
Gross
Return
Exempt
Premiums
at 3% of
ID #
Premiums
Premiums
Premiums
Taxable
Gross
Premiums
Grand Totals:
Reset Entire Form
RETURN TO PAGE 1
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