Form TC-420PC Fillable Self-Insurer’s Tax Payment Coupon
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

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) (text) (text) (text) (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