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