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Form 207c Ext - Application For Extension Of Time To File Connecticut Captive Insurane Premiums Tax Return - 2016

Department of Revenue Services

Form 207C EXT

2016

State of Connecticut

Application for Extension of Time to File

PO Box 2990

Hartford CT 06104-2990

Connecticut Captive Insurance Premiums

(Rev. 12/16)

Tax Return

207CEXT 1216W 01 9999

See instructions on back before completing this application. Complete this form in blue or black ink only. Type or print.

Name of company

Connecticut Tax Registration Number



Number and street

PO Box

For DRS



Use Only

M M - D D - Y Y Y Y

City, town, or post ofﬁ ce

State

ZIP code

Federal Employer ID Number (FEIN)



This is not an extension of time to pay your tax. Penalties and inerest may apply. See instructions.

I request a 12-month extension of time to March 1 of the succeeding calendar year, to ﬁ le a Connecticut captive insurance

premiums tax return for calendar year above.

The reason for the Connecticut extension request is:

Notiﬁ cation will be sent only if the extension request is denied.

1. Total tax liability for the calendar year: You may estimate this amount. Minimum tax $7,500.00.

You must enter an amount on Line 1. If you do not expect to owe tax, enter zero “0.” ............... 1

.00

2. Any overpayments applied to the calendar year. ......................................................................... 2

.00

3. Balance due: Subtract Line 2 from Line 1. Pay in full with this form. If Line 2 is greater

than Line 1, enter zero “0.” ........................................................................................................... 3



.00

Declaration: I declare under the penalty of law that I have examined this return and, to the best of my knowledge and belief, it is true, complete, and correct. I

understand the penalty for willfully delivering a false return or document to the Department of Revenue Services (DRS) is a ﬁ ne of not more than $5,000, imprisonment

for not more than ﬁ ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.

Signature of principal ofﬁ cer

Title

Date

Sign

Here

Print name of principal ofﬁ cer

Telephone number

Keep a

copy of

Paid preparer’s signature

Date

Preparer’s SSN or PTIN