Free TC-420, Utah Self Insurer's Tax Return - Utah

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Utah State Tax Commission 210 N 1950 W · SLC, UT 84134 · www.tax.utah.gov

TC-420
Rev. 2/08

Self Insurer's Tax Return
Name and address (please correct any errors)

Account Number / FEIN
Start below this line. Enter your company name and address.
Use this number for all references

Tax Period

Return due on or before

1. Gross tax due (Schedule A, Line 5, times .0775)........................................................................... 2. CREDIT: Rocky Mtn Cntr for Occupational & Environmental Health (see instructions)..... 3. Tax after credit (line 1 minus line 2) ................................................................................... 4. Prepayments Refund applied from previous quarter 1st Quarter....................................... 2nd Quarter...................................... 3rd Quarter ...................................... $ $ $ $

$ $ $

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$ $ $

5. Total prepayments (add all totals from line 4) .......................................................................... 6. Tax due with return (if line 3 is greater than line 5, subtract line 5 from line 3 and enter amount) ...... 7. Overpayment (if line 5 is greater than line 3, subtract line 3 from line 5 and enter amount) ...............
Check box at right if you want refund applied to tax for 2007 .........................................

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Please remit the amount of tax due from line 6. Make check payable to Utah State Tax Commission, and return ENTIRE form, coupon and payment to: Utah State Tax Commission, 210 N 1950 W, SLC UT 84134-0130
PLEASE RETURN ORIGINAL. MAKE A COPY FOR YOUR RECORDS.
I declare under the penalties provided by law that to the best of my knowledge this return, including any accompanying schedules, is a true, complete and correct return.
Authorized Signature Return Prepared By Title Title Date Date

SELF INSURER'S TAX RETURN ­ TC-420
Federal ID Number Filing Period Due Date

TC-420_1.ai Rev. 12/06

Amount Paid
Make check or money order payable to the Utah State Tax Commission. Do not send cash. Do not staple check to this coupon.

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UTAH STATE TAX COMMISSION SELF INSURER'S TAX RETURN 210 N 1950 W SLC UT 84134-0130
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Self Insurer's Tax Return
General Instructions
On or before March 31st of each year, employers authorized by the Industrial Commission to provide their own worker's compensation coverage are required to pay an amount equivalent to the premium tax paid by private insurance carriers providing worker's compensation coverage. Payroll is classified based on the general nature of the employer's business as defined by the National Council on Compensation Insurance (NCCI) rather than separate occupations. Employers with multiple corporations or physically separated operations or divisions are required to file a combined return with a supplemental schedule listing the location and total payroll of each company, division or operation. Self insured employers are required by statute to have an annual "Workers Compensation Experience Rating" certification (experience modification) from the designated rating agency - currently NCCI. The effective date of the certified rate should be such that the majority of the taxable year is covered by the certification. Employers MUST attach their "Workers Compensation Experience Rating" certification. The experience rate without a certification rating is "2." The "Safety Factor" adjustment is based on the experience rating and is the only other adjustment allowed to standard premiums. Experience Rating Less than 0.91 Less than 1.01 Less than 1.11 Less than 1.21 Greater than 1.20 Safety Factor 0.56 0.78 1.00 1.22 1.44

TC-420_2.ai Rev. 2/08

Self Insurer's Tax Return (Form TC-420)
Line 1 Gross Tax Due: Multiple the rate times the Taxable Premiums (Schedule A, Line 5). Line 2 Occupational health and safety center credit: Self-insured employers may offset a qualified cash donation to the Rocky Mountain Center for Occupational & Environmental Health against the gross tax assessment. The amount of the credit is the lesser of the total donation or .10 percent of the premium assessment. Attach a copy the receipt provided by this occupational health and safety center. Line 4 Prepayments: Companies required to make quarterly prepayments and any company with a carryover from prior year overpayments, list payments in the applicable boxes. Line 6 Tax due: Remit this amount using the last coupon included in your prior year coupon booklet. If this coupon is not available, complete the coupon on the bottom of the return. Line 7 Overpayment: Overpayments may be applied to the following year's prepayment or liability by checking the applicable box. Allow 90 days for refunds.

Schedule A
Previous Filers: Columns A (Class Number), B (Name of Classification) and F (Rate) should be preprinted based on your prior year return. If the nature of your business has changed, please contact the Tax Commission for help in modifications. New Filers: Please contact the Tax Commission with classifications to get the appropriate rates for Utah. Column C Total Payroll: Include all taxable payroll. Column D Excluded Payroll: Payroll of designated executive officers residing in Utah is excluded for amounts exceeding $1,600 per week ($83,200 annually). These designated officers are generally limited to the "registered" officers of the corporation and must be declared. Unless otherwise stated, the schedule, listing individual officers, their title and excluded amount, supporting the deduction in the current return is the basis for the succeeding year's declaration of excluded officers. Line 4 Safety Factor: Based on "Experience Rating" below, determine the applicable safety factor from the following schedule:

Other Information
The penalty for failure to file a tax due return by the due date is the greater of $20 or 10 percent of the unpaid tax. In addition, if a tax balance remains unpaid 90 days after the due date, a second penalty, the greater of $20 or 10 percent of the tax balance, will be added for failure to pay timely. The penalty for failure to pay tax due as reported on a timely filed return, or within 30 days of a notice of deficiency, is the greater of $20 or 10 percent of the tax due. Interest will be assessed at the rate prescribed by law from the original due date until paid in full. For information, find Pub 58, Interest and Penalties, online at tax.utah.gov/forms/pubs. Or request Pub 58 by calling (801) 297-2200, or by writing the Utah State Tax Commission, 210 North 1950 West, Salt Lake City, Utah 84134. If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811 or TDD (801) 297-3819. Please allow three working days for a response.