Form 207/207 Hcc Ext - Application For Extension Of Time To File Domestic Insurance Premiums Tax Return Or Health Care Center Tax Return 2007

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Department of Revenue Services
Form 207/207 HCC EXT
207/207 HCC EXT
State of Connecticut
PO Box 2990
2007
Application for Extension of Time to File
Hartford CT 06104-2990
Domestic Insurance Premiums Tax Return or
(Rev. 12/07)
Health Care Center Tax Return
Read instructions on reverse before completing this application. Complete this return in blue or black ink only.
Name of Company
Connecticut Tax Registration Number
Taxpayer
Address
Number and Street
PO Box
Date Received (DRS Use Only)
Please Type
or Print.
City, Town, or Post Office
State
ZIP Code
Federal Employer ID Number (FEIN)
This is not an extension of time to pay tax. Penalties and interest may apply. See instructions.
I request a 12-month extension of time, to March 1, 2009, to file a Connecticut domestic insurance premiums tax return for calendar
year 2007.
I request a 12-month extension of time, to March 1, 2009, to file a Connecticut health care center tax return for calendar year 2007.
The reason for the Connecticut extension request is: ______________________________________________________________
_________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
You will be notified only if your request is denied.
1. Total tax liability for 2007: You may estimate this amount.
You must enter an amount on Line 1. If you do not expect to owe tax, enter zero “0.” ................... 1
00
2. 2007 Connecticut estimated tax payments and any overpayments credited to 2007 .....................
00
2
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.” ..............................................................................
00
3
Make check payable to: Commissioner of Revenue Services.
Write the company’s Connecticut Tax Registration Number and “2007 Form 207/207 HCC EXT” on your check.
Mail to:
Department of Revenue Services
State of Connecticut
PO Box 2990
Hartford CT 06104-2990
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 (DRS) 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 Principal Officer
Title
Date
Sign Here
Print Name of Principal Officer
Telephone Number
Keep a copy
(
)
of this return
Paid Preparer’s Signature
Date
Preparer’s SSN or PTIN
for your
records
Firm Name and Address
FEIN

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