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

Print Form
Utah State Tax Commission 210 North 1950 West · Salt Lake City, UT 84134 · www.tax.utah.gov

Clear form TC-420A
Rev. 12/06

Self Insurer's Tax Return
Schedule A: Report of Payroll

Taxpayer: ____________________
Class Code Information A. Class Number B. Name of Classification

FEIN: ____________
Payroll (whole dollars) D. Excluded Payroll
(attach detail)

Period: ____________
Calculation of Premiums G. Standard Premium
(Column E x Column F)

C. Total Payroll

E. Net Payroll

F. Rate

00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00

00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00

00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00
1 2 3 4 5

1. Total standard premium (add column G)....................................................................................................................... 2. Experience modifier -- minimum rate is 0.5 (attach certification) ......................................................................... 3. Adjusted premium after modifier (line 1 x line 2)........................................................................................................ 4. Safety factor ....................................................................................................................................................................... 5. Taxable Premium (line 3 x line 4) ..................................................................................................................................

00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00
Print Form

IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.

Clear form