Form Rct-123 - Gross Premium Tax Surplus Lines Agents

RCT-123 (11-11) (I)

1230011101

GROSS PREMIUM TAX

SURPLUS LINES AGENTS

Bureau of Corporation Taxes

2011 REPORT

PO BOX 280407

Harrisburg PA 17128-0407

CORP TAX ACCOUNT ID

NAME

(Department Use Only)

Date Received

ADDRESS

FEDERAL ID (EIN)

CITY

STATE

ZIP CODE

Check to indicate a change of address

Check to send all correspondence to preparer.

PSLA 4-digit Customer ID#

First Report

Amended Report (See instructions.)

Last Report (See instructions.)

ANNUAL PAYMENTS

TAX YEAR ENDING

DUE DATE

12/31/11

01/31/12

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

Surplus Lines

GROSS PREMIUMS -

125166

GRAND TOTALS

PLEASE CHECK THIS BLOCK 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.)

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