Form 207hcc - Health Care Center Tax Return - 2005 printable pdf download

Department of Revenue Services

Form 207HCC

2005

PO Box 2990

Health Care Center Tax Return

Hartford CT 06104-2990

(Rev. 12/05)

Complete the return in blue or black ink only.

General Information:

A. Return Status:

Amended

Final

B. Change of:

Address

C. If this is a short period, enter period covered by this return: ______________________________________________________________________

D. If this is a final return, has the insurance company:

Merged/Reorganized

___________________________________________________

(Enter Survivor’s Connecticut Tax Registration Number)

E. The health care center is currently under:

Receivership

Rehabilitation

Name of Company

Connecticut Tax Registration Number

Taxpayer

Address

Number and Street

PO Box

Date Received (DRS Use Only)

(Type or Print)

City or Town

ZIP Code

Federal Employer Identification Number

1 Total net direct subscriber charges less returned charges, including cancellations. (See instructions.)

Subscriber charges received from:

2 The State of Connecticut to provide health care coverage for state employees, retirees, or their dependents

The State of Connecticut to provide health care coverage for retired teachers, their spouses, or their surviving

spouses covered by plans offered by the State Teachers’ Retirement System

4 Connecticut municipalities to provide health coverage for their employees and dependents

Nonprofit organizations or community action agencies to provide health coverage for their employees and

dependents

6 The federal government to provide coverage for Medicare patients

7 The State of Connecticut to provide health care coverage for Medicaid recipients

The State of Connecticut to provide health care coverage for eligible beneficiaries under the HUSKY Plan,

Part A; HUSKY Plan, Part B; or the HUSKY Plus programs

9 The State of Connecticut to provide health care coverage for recipients of state administered general assistance

10 The federal Employees Health Benefits Fund to provide coverage for qualified enrollees

Individuals eligible for a health coverage tax credit; and individuals eligible for a retirement benefit from the

Connecticut municipal employees’ retirement system and their dependents

12 Total deductions (Add Lines 2 through 11.)

13 Subtract Line 12 from Line 1.

14 Health care center tax: Multiply Line 13 by 1.75% (.0175).

15a General business tax credits (Attach Form CT-1120K, Business Tax Credit Summary. See instructions.)

15a

15b Multiply Line 14 by 70% (.70).

15b

15c Enter Line 15a or Line 15b, whichever is less.

15c

16 Balance of tax payable (Subtract Line 15c from Line 14. If less than zero, enter zero “0.”)

17 Enter prior year overpayment(s).

18 Payments made with estimated tax payment coupons (Forms 207HCC ESA, ESB, ESC, and ESD).

19 Payments made with extension request (Form 207/207HCC EXT). (See amended returns on back.)

20 Total prior payments (Add Lines 17, 18, and 19.)

21 If Line 20 is greater than Line 16, enter amount overpaid.

22 Amount to be: Credited to 2006 estimated tax (22a) $_______________ Refunded (22b)$______________

23 If Line 16 is greater than Line 20, enter amount owed.

24 If Late: penalty (24a) $__________________ plus interest (24b) $__________________(See instructions.)

25 Interest on underpayment of estimated tax (Attach Form 207I. See instructions on back.)

26 Balance due with this return (Make check payable to: Commissioner of Revenue Services)

Declaration: I declare under the 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