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Form 207F EXT

Department of Revenue Service



State of Connecticut

PO Box 2990

Application for Extension of Time to File

Hartford CT 06104-2990

Insurance Premiums Tax Return

(Rev. 12/15)

Nonresident and Foreign Companies

Read instructions on reverse before completing this application. Complete this application 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.

request a 12-month extension of time to March 1

of the succeeding calendar year

(or to March

1of the next succeeding

calendar

yearfor a second request), to file a Connecticut nonresident and foreign insurance companies premiums tax return

for calendar year above.

The reason for the Connecticut extension request is _______________________________________________________

_________________________________________________________________________________________________

You will be notified only if your request is denied.

1. Total insurance premiums tax liability for

the calendar

year: 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

Calendar year

Connecticut estimated tax payments and any overpayments

applied

to the calendar year .................................................................................................. 2

3. Insurance premiums tax 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.” ...........................................................



Pay Electronically

Mail paper return to:

Department of Revenue Services

Visit the Department of Revenue Services (DRS) Taxpayer

State of Connecticut

Service Center (TSC) at to pay

PO Box 2990

electronically.

Hartford CT 06104-2990

Make check payable to Commissioner of Revenue

Services.

Write the company’s Connecticut Tax Registration Number

and “Form 207F EXT” on your check.

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 DRS is a fine of not more than $5,000, 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

for your

Paid preparer’s signature

Date

Preparer’s SSN or PTIN

records.

Firm name and address

FEIN

P:\Special\AFP\PROD\FORMS\15\Form\Form 207F EXT\Form 207F EXT 20151006.indd

20151006

11:06 AM

Form 207f Ext Draft - Application For Extension Of Time To File Insurance Premiums Tax Return Nonresident And Foreign Companies

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