Form Ct-1120 Pic - Information Return For Passive Investment Companies

Form Ct-1120 Pic - Information Return For Passive Investment Companies - 2005 Page 2

6. Indicate the method used to allocate expenses and employee costs to the PIC:

I.R.C. §482 Type Method (See instructions.)

Safe Harbor Method elected (See instructions.):

____ Percentage of Time

____ Percentage of Loans

The PIC hereby affirms that the Applicable Period selected under the safe harbor methods in either Line 5 or Line 6 is representative

of, or generally no less than, its level of employment for the entire year.

7. Enter the amount of expenses and employee costs to be allocated to the PIC: __________________________

(Attach detailed schedule. See instructions.)

8. Enter the amount of the PIC’s total gross receipts (Attach detailed schedule.): __________________________

9. Enter the amount of total dividends issued by the PIC (Attach detailed schedule.): _______________________

DECLARATION: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) 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 is a fine of not more than $5,000, or imprisonment for not more than five 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 Corporate Officer

Title

Date

Telephone Number

(

)

SIGN HERE

Paid Preparer’s Signature

Date

Preparer’s SSN or PTIN

Keep a copy