Form Tc-420pc - Tax Payment Coupon For Utah Self-Insurer
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1Utah State Tax Commission
Self-Insurer’s Tax Payment Coupon
TC-420PC
Rev. 9/11
Payment Coupon
Electronic Payment
Use payment coupon TC-420PC to make quarterly insurance
You may make this payment online at taxexpress.utah.gov.
premium tax payments.
___________________
Instructions
If you have questions about the Self-Insurer’s Tax, please call
1. Do not submit this form if no payment is due.
801-297-2200, or 1-800-662-4335 if calling from outside the Salt
2. Quarterly prepayments are due only if the prior year’s tax was
Lake area.
$10,000 or more.
If you need an accommodation under the Americans with
3. Quarterly prepayments may be based on either:
Disabilities Act, contact the Tax Commission at 801-297-3811 or
a. 27 percent of the prior year’s tax liability, or
TDD 801-297-2020. Please allow three working days for a
b. estimated insurance premium tax for the calendar quarter.
response.
4. Return this coupon and payment to the address listed on the
coupon by the due date. Due dates are April 30, July 31 and
Oct. 31 of the taxable year. Final payment is due with the
annual return, which is due March 31.
5. The return and return payment are due on March 31.
6. Penalty and interest charges apply to any underpayment.
Where to File
Send your payment coupon and payment to :
Utah State Tax Commission
Self-Insurer’s Tax Payment
210 N 1950 W
Salt Lake City, UT 84134-0130
Separate and return only the bottom portion.
Tax Payment Coupon for Utah Self-Insurer, TC-420PC
TC-420PC
Rev. 9/11
Self-Insurer Account ID
Taxable Year Ending (mm/dd/yyyy)
Payment Type:
00
Amount Paid:
1st qtr. estimate
Annual return pmt.
2nd qtr. estimate
Make check or money order payable to the Utah State Tax
Commission. Do not send cash. Do not staple check to
3rd. qtr. estimate
coupon. Do not send check stub.
Name of Filer
Address
City
State
ZIP Code
Mail to: Utah State Tax Commission, 210 N 1950 W, SLC UT 84134-0130
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