Form 207 Hcc - Health Care Center Tax Return

Form 207HCC Instructions

General Instructions

Line 18: Enter payment made with Form 207/207 HCC EXT, Application

Complete this return in blue or black ink only.

for Extension of Time to File Domestic Insurance Premiums Tax Return

Due Date: This return is due on or before March 1, 2014, for health care

or Health Care Center Tax Return. To request an extension of time to ﬁ le

center tax liability for calendar year 2013.

Form 207 HCC, you must ﬁ le Form 207/207 HCC EXT and pay all the

tax you expect to owe on or before March 1, 2014.

Attachments: Attach the following to this return:

 The Statement of Revenue and Expenses from the Annual

Line 19: If Line 15 is greater than Line 19, subtract Line 19 from

Line 15: This is the amount of tax you owe.

Statement ﬁ led with the Connecticut Insurance Department;

 A copy of Schedule T;

Line 21: Add Line 21a and Line 21b. Your election to credit your

 2013 Form 207I, if applicable; and

overpayment to your 2014 estimated health care center tax or to have

 2013 Form CT-207K, if applicable.

your overpayment refunded to you is irrevocable.

Rounding Off to Whole Dollars: You must round off cents to the nearest

Line 21a: Enter the amount of overpayment you want applied to

whole dollar on your return and schedules.

your 2014 estimated health care centers’ subscriber charges. The

Filing an Amended Return: To ﬁ le an amended return, complete a new

overpayment will be treated as an estimated tax payment made on the

Form 207 HCC using the correct ﬁ gures and information for the reporting

ﬁ fteenth day of March of the calendar year it is being applied to if this

period. Enter the amount paid with the original return on Line 18.

return is ﬁ led on time or if the tax return is ﬁ led within the extension

period if a timely request for extension was ﬁ led. A request to apply

Line Instructions

an overpayment to the following year is irrevocable.

Line 1: Enter total net direct subscriber charges received during calendar

Line 21b: Enter the amount of overpayment you want refunded to you.

year 2013 on any new or renewal contract.

Lines 21c through 21e: Get your refund faster by choosing direct deposit.

Line 2: Enter net direct subscriber charges received during calendar year

Complete Lines 21c, 21d, and 21e to have your refund directly deposited

2013 on any contract or policy entered into with the State of Connecticut

into your checking or savings account.

to provide health care coverage to state employees, retirees, or their

No. 101

Name of Depositor

Enter your nine-digit bank routing number and

dependents.

Date

Street Address

City, State, Zip Code

Pay to the

your bank account number in Lines 21d and

Order of

Line 3: Enter net direct subscriber charges received during calendar year

21e. Your bank routing number is the ﬁ rst nine-

2013 on any contract or policy entered into with the State of Connecticut

Name of your Bank

Street Address

digit number printed on your check or savings

City, State, Zip Code

on or after February 1, 2000, to provide health care coverage to retired

withdrawal slip. Your bank account number

092125789

091 025 025413

0101

teachers, their spouses, or their surviving spouses covered by plans

generally follows the bank routing number. Do

Routing Number

Account Number

offered by the State Teachers’ Retirement System.

not include the check number as part of your account number. Bank account

Line 4: Enter net direct subscriber charges received during calendar year

numbers can be up to 17 characters. If any of the bank information you supply

2013 on any contract or policy entered into on or after July 1, 2001, to provide

for direct deposit does not match or you close the applicable bank account

health care coverage for employees of a Connecticut municipality and their

prior to the deposit of the refund, your refund will automatically be mailed.

dependents under a plan procured under Conn. Gen. Stat. §5-259(i).

Line 21f: Federal banking rules require DRS to request information about

Line 5: Enter net direct subscriber charges received during calendar year

foreign bank accounts when the taxpayer requests the direct deposit of

2013 on any contract or policy entered into: (A) On or after July 1, 2001,

a refund into a bank account. If the refund is to be deposited in a bank

to provide health care coverage for employees of a Connecticut nonproﬁ t

outside of the United States, DRS will mail the refund.

organization and their dependents under a plan procured under Conn.

Line 23a: Late Payment Penalty: Multiply Line 22 by 10%. Enter the

Gen. Stat. §5-259(i); and (B) On or after July 1, 2005, to provide health

result or $50, whichever is greater.

care coverage for employees of a community action agency and their

Line 23b: Multiply Line 22 by 1% per month or fraction of a month from

dependents under a plan procured under Conn. Gen. Stat. §5-259(i).

the original due date of the return to the date of payment.

Line 6: Enter net direct subscriber charges received during calendar

Line 24: If estimated tax was underpaid, complete and attach Form 207I,

year 2013 from the federal government to provide health care coverage

Underpayment of Estimated Insurance Premiums Tax or Health Care

for Medicare patients.

Center Tax, and enter the amount from Line 22 of Form 207I.

Line 7: Enter net direct subscriber charges received during calendar year

Line 25: Add the amounts from Lines 22, 23, and 24.

2013 from a contract or policy entered into with the State of Connecticut

Make check payable to Commissioner of Revenue Services. Write

to provide health care coverage to Medicaid recipients.

“2013 Form 207 HCC” and your Connecticut Tax Registration Number

Line 8: Enter net direct subscriber charges received during calendar

on the front of your check. DRS may submit your check to your bank

year 2013 from any contract or policy entered into with the State of

electronically. Mail to the address on the front of this return.

Connecticut on or after April 1, 1998, to provide health care coverage

Signature: The treasurer of the company, or a principal ofﬁ cer of the

to eligible beneﬁ ciaries under the HUSKY Plan, Part A; HUSKY Plan,

company, must sign Form 207 HCC.

Part B; or the HUSKY Plus programs.

Paid Preparer Signature: A paid preparer must sign and date

Line 9: Enter net direct subscriber charges received during calendar year

Form 207 HCC. Paid preparers must also enter their Social Security

2013 from the federal Employee Health Beneﬁ ts Fund to provide health

Number (SSN) or Preparer Tax Identiﬁ cation Number (PTIN) and their

care coverage for U.S. government employees, retired U.S. government

ﬁ rm’s Federal Employer ID Number (FEIN) in the spaces provided.

employees, certain former U.S. government employees and eligible

members of their families.

Pay Electronically: Visit to make a direct tax payment.

Using this option authorizes DRS to electronically

Line 10: Enter net direct subscriber charges received during calendar

withdraw a payment from your bank account (checking

year 2013 on any contract or policy entered into: (A) On or after July 1,

or savings) on a date you select up to the due date.

2003, to provide health care coverage for individuals eligible for a health

If you pay electronically, you must still ﬁ le your return on or before the

coverage tax credit and their dependents under a plan procured under

due date.

Conn. Gen. Stat. §5-259(i); and (B) On or after July 1, 2005, to provide

health care coverage for individuals eligible for a retirement beneﬁ t

For More Information: Call DRS during business hours, Monday

from the Connecticut municipal employees’ retirement system and their

through Friday:

dependents under a plan procured under Conn. Gen. Stat. §5-259(i).

•

1-800-382-9463 (Connecticut calls outside the Greater Hartford

Line 14: If your company is claiming Connecticut tax credits,

calling area only); or

Form CT-207K, Insurance/Health Care Tax Credit Schedule, must be

•

860-297-5962 (from anywhere).

completed and attached to this return.

TTY, TDD, and Text Telephone users only may transmit inquiries

Line 17: Enter estimated payments made with Forms 207 HCC ESA,

anytime by calling 860-297-4911.

ESB, ESC, and ESD.

Forms and Publications: Visit the DRS website at

to download and print Connecticut tax forms and publications.

Form 207 HCC (Rev. 12/13)

Form 207 Hcc - Health Care Center Tax Return - 2013 Page 2

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