FILL IN FORM USING ALL CAPS.DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD. ENTER DATES AS MMDDYYYY. USE WHOLE DOLLARS ONLY.
1321016105
OFFICIAL USE ONLY
rct-132a
Date Received (Official Use Only)
PagE 1 Of 3
(03-16) (FI)
PEnnSylVanIa tItlE InSUrancE cOMPany
c
SharES taX rEPOrt
START
Revenue ID
Federal ID (FEIN)
Parent Corporation (FEIN)
Shares Tax:
01 01 20
_ _
Due Date: March 15
Please select correct letter in drop down
Taxpayer Name
Check to Indicate a Change of Address
Send All Correspondence to the Preparer
First Line of Address
Amended Report (Include REV-1175.)
First Report
Second Line of Address
Payment Made Electronically
KOZ/EIP
City
State
ZIP
Final Report (See Instructions.)
Phone
Out of Existence Date:
Email
USE whOlE DOllarS Only
1a.
1a. Shares Tax (Page 2, Line 11)
1b.
1b. Loans Tax (Leave blank for tax periods beginning after Dec. 31, 2013.)
1c.
1c. Total Shares Tax
2.
2.
Total Estimated Payments
3.
3.
Total Payments Carried Forward From Prior Year Return
4.
4.
Total “Restricted” Tax Credits
5.
5.
Total Credit: (Line 2 plus Line 3 plus Line 4)
6.
Tax Due: (If Line 1c is more than Line 5, enter the difference here.)
6.
7.
Remittance
7.
8.
Overpayment: (If Line 5 is more than Line 1c, enter the difference here.)
8.
9.
Refund: (Amount of Line 8 to be refunded after offsetting all unpaid liabilities)
9.
10. Transfer: (Amount of Line 8 to be credited to the next tax year after offsetting
10.
all unpaid liabilities)
1321016105
corporate Officer Information:
Social Security
Number of Officer
Officer Last Name
Officer First Name
Phone
Title of Officer
Email
I affirm under penalties prescribed by law, this report, including any accompanying schedules and statements, has been examined by me and to the best of my
knowledge and belief is a true, correct and complete report. If this report is an amended report, the taxpayer hereby consents to the extension of the assessment
period for this tax year to one year from the date of filing of this amended report or three years from the filing of the original report, whichever period last expires,
and agrees to retain all required records pertaining to that tax and tax period until the end of the extended assessment period, regardless of any statutory
provision providing for a shorter period of retention. For purposes of this extension, an original report filed before the due date is deemed filed on the due date.
I am authorized to execute this consent to the extension of the assessment period.
Signature of Officer
Date
Signature of Officer – Please sign after printing
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1321016105
OFFICIAL USE ONLY
rct-132a
Date Received (Official Use Only)
PagE 1 Of 3
(03-16) (FI)
PEnnSylVanIa tItlE InSUrancE cOMPany
c
SharES taX rEPOrt
START
Revenue ID
Federal ID (FEIN)
Parent Corporation (FEIN)
Shares Tax:
01 01 20
_ _
Due Date: March 15
Please select correct letter in drop down
Taxpayer Name
Check to Indicate a Change of Address
Send All Correspondence to the Preparer
First Line of Address
Amended Report (Include REV-1175.)
First Report
Second Line of Address
Payment Made Electronically
KOZ/EIP
City
State
ZIP
Final Report (See Instructions.)
Phone
Out of Existence Date:
Email
USE whOlE DOllarS Only
1a.
1a. Shares Tax (Page 2, Line 11)
1b.
1b. Loans Tax (Leave blank for tax periods beginning after Dec. 31, 2013.)
1c.
1c. Total Shares Tax
2.
2.
Total Estimated Payments
3.
3.
Total Payments Carried Forward From Prior Year Return
4.
4.
Total “Restricted” Tax Credits
5.
5.
Total Credit: (Line 2 plus Line 3 plus Line 4)
6.
Tax Due: (If Line 1c is more than Line 5, enter the difference here.)
6.
7.
Remittance
7.
8.
Overpayment: (If Line 5 is more than Line 1c, enter the difference here.)
8.
9.
Refund: (Amount of Line 8 to be refunded after offsetting all unpaid liabilities)
9.
10. Transfer: (Amount of Line 8 to be credited to the next tax year after offsetting
10.
all unpaid liabilities)
1321016105
corporate Officer Information:
Social Security
Number of Officer
Officer Last Name
Officer First Name
Phone
Title of Officer
Email
I affirm under penalties prescribed by law, this report, including any accompanying schedules and statements, has been examined by me and to the best of my
knowledge and belief is a true, correct and complete report. If this report is an amended report, the taxpayer hereby consents to the extension of the assessment
period for this tax year to one year from the date of filing of this amended report or three years from the filing of the original report, whichever period last expires,
and agrees to retain all required records pertaining to that tax and tax period until the end of the extended assessment period, regardless of any statutory
provision providing for a shorter period of retention. For purposes of this extension, an original report filed before the due date is deemed filed on the due date.
I am authorized to execute this consent to the extension of the assessment period.
Signature of Officer
Date
Signature of Officer – Please sign after printing
Reset Entire Form
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1321016205
Revenue ID
rct-132a
PagE 2 Of 3
(03-16) (FI)
Lines 9 and 14 should be 1.000000 or less.
c
USE whOlE DOllarS Only
calculation of Shares tax
1.
Current Year Value of Shares (Schedule A, Line 31)
1.
2.
First Prior Year Value of Shares
2.
3.
Second Prior Year Value of Shares
3.
4.
Third Prior Year Value of Shares
4.
5.
Fourth Prior Year Value of Shares
5.
6.
Fifth Prior Year Value of Shares
6.
7.
Sum of Value of Shares (Total Line 1 through Line 6)
7.
8.
Taxable Shares (Line 7 divided by 6 or number of years in existence if less than 6)
8.
9.
Shares Tax Apportionment (Line 14 below)
9.
10.
Total Amount of Shares Subject to Tax (Line 8 times Line 9)
10.
11.
Tax (Line 10 times tax rate – See Instructions.)
11.
calculation of Shares tax apportionment
12.
Total Receipts Inside PA (Line 17a below)
12.
13.
Total Receipts Everywhere (Line 17b below)
13.
14.
Receipts Factor (Line 12 divided by Line 13; carry to 6 decimal places)
14.
InSIDE PEnnSylVanIa
EVErywhErE
receipts factor
15.
Receipts from Issuance of Title Insurance
15a.
15b.
16.
Other Receipts (Attach schedule.)
16a.
16b.
17.
Total Receipts (Line 15 plus Line 16)
17a.
17b.
Mergers (Complete only if applicable.)
Non-surviving Entity
Date Combined
Revenue ID
1.
2.
3.
(Attach schedule if additional space is needed.)
Preparer’s Information:
1321016205
Firm Name
Individual Preparer Name
Firm FEIN
Phone
Address
Email
City
Social Security Number
or PTIN
State
ZIP
I affirm under penalties prescribed by law, this report, including any accompanying schedules and statements, has been prepared by me and to the best of
my knowledge and belief is a true, correct and complete report.
Signature of Preparer
Date
Signature of Preparer – Please sign after printing
Reset Entire Form
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1321016305
Revenue ID
rct-132a
PagE 3 Of 3
(03-16) (FI)
c
USE whOlE DOllarS Only
SchEDUlE a – calculation of current year – taxable Shares
1st Quarter
1.
Book Value of Capital Stock Paid In
1.
2.
Book Value of Surplus
2.
3.
Book Value of Undivided Profits
3.
4.
Book Value of Unearned Premium Reserve
4.
5.
Total (Line 1+2+3+4)
5.
6.
Book Value of U. S. Obligations
6.
7.
Quarterly Book Value (Line 5 minus Line 6)
7.
2nd Quarter
8.
8.
Book Value of Capital Stock Paid In
9.
9.
Book Value of Surplus
10.
10. Book Value of Undivided Profits
11.
11. Book Value of Unearned Premium Reserve
12.
12. Total (Line 8+9+10+11)
13.
13. Book Value of U. S. Obligations
14.
14. Quarterly Book Value (Line 12 minus Line 13)
3rd Quarter
1
5. Book Value of Capital Stock Paid In
15.
16. Book Value of Surplus
16.
17. Book Value of Undivided Profits
17.
18. Book Value of Unearned Premium Reserve
18.
1
9. Total (Line 15+16+17+18)
19.
20. Book Value of U. S. Obligations
20.
21. Quarterly Book Value (Line 19 minus Line 20)
21.
4th Quarter
22.
22. Book Value of Capital Stock Paid In
23.
23. Book Value of Surplus
24.
24. Book Value of Undivided Profits
25.
25. Book Value of Unearned Premium Reserve
26.
26. Total (Line 22+23+24+25)
27.
27. Book Value of U. S. Obligations
28.
28. Quarterly Book Value (Line 26 minus Line 27)
calcUlatIOn
29.
29. Number of Quarters in Existence for Current Tax Year
30.
30. Total Book Value (Line 7+14+21+28)
31.
31. Current Year Value of Shares (Line 30 divided by Line 29)
Carry the amount on Line 31 to Page 2, Line 1.
1321016305
1321016305
1321016305
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