Pennsylvania Gross Receipts Tax (GRT) Report

Gross Receipts Tax (GRT) Report
Gross Receipts Tax (GRT) Report -- Managed Care Organizations (RCT-113B) -- Print Only Version
1130212101

RCT-113B

(09-14)

PAGE 1 OF 2

Date Received (Official Use Only)

GROSS RECEIPTS TAX (GRT) REPORT
MANAGED CARE ORGANIZATIONS

C
Tax Year Begin:

Revenue ID

Federal ID (FEIN)

Parent Corporation (FEIN)

12/31/20_ _
Due Date: March 15
Tax Year End:

Taxpayer Name

Check to Indicate a Change of Address
Send All Correspondence to the Preparer
Amended Report
First Report
Payment Made Electronically

First Line of Address
Second Line of Address
City

State

ZIP

Last Report

Phone

Out of Existence as of:

Email

USE WHOLE DOLLARS ONLY

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4.
5.
6.
7.
8.
9.
10.

Gross Receipts Tax Managed Care Organizations (Page 2, Line 2)
Total Estimated Payments
Total Payments Carried Forward From Prior Year Return
Total “Restricted” Tax Credits
Total Credit: (Line 2 plus Line 3 plus Line 4)
Tax Due: (If Line 1 is more than Line 5, enter the difference here.)
Remittance: (Include interest and penalty, if applicable.)
OVERPAYMENT: (If Line 5 is more than Line 1, enter the difference here.)
Refund: (Amount of Line 8 to be refunded after offsetting all unpaid liabilities)
Transfer: (Amount of Line 8 to be credited to the next tax year after offsetting
all unpaid liabilities)

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4.
5.
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7.
8.
9.
10.

1130212101

Corporate Officer Information:

Officer Last Name

Social Security
Number of Officer

Officer First Name
Title of Officer

Phone
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

1130212201

RCT-113B

(09-14)

Revenue ID

PAGE 2 OF 2

SOURCE OF GROSS RECEIPTS

USE WHOLE DOLLARS ONLY

1.
2.

Gross Receipts from GRT MMCO Revenue Report issued by the
Department of Public Welfare
Managed Care Organizations GRT (Line 1 times tax rate - See Instructions)

1.
2.

1130212201

Preparer’s Information:

Firm Name
Firm FEIN
Address
City
State
ZIP

C

Individual Preparer Name
Phone
Email
Social Security Number
or PTIN

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