Department of Revenue Services
PO Box 2990
Health Care Center Tax Return
Hartford CT 06104-2990
Complete the return in blue or black ink only.
A. Return Status:
B. Change of:
C. If this is a short period, enter period covered by this return: ______________________________________________________________________
D. If this is a final return, has the insurance company:
(Enter Survivor’s Connecticut Tax Registration Number)
E. The health care center is currently under:
Name of Company
Connecticut Tax Registration Number
Number and Street
Date Received (DRS Use Only)
(Type or Print)
City or Town
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
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.)
15b Multiply Line 14 by 70% (.70).
15c Enter Line 15a or Line 15b, whichever is less.
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
Print Name of Principal Officer
Keep a copy
of this return
Paid Preparer’s Signature
Preparer's PTIN or SSN
Firm Name and Address
Federal Employer Identification Number