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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

2. 2007 Connecticut estimated tax payments and any overpayments credited to 2007 .....................

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.” ..............................................................................

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

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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