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207/207 HCC EXT

Department of Revenue Services

Form 207/207 HCC EXT

20__

State of Connecticut

PO Box 2990



Application for Extension of Time to File

Hartford CT 06104-2990

Domestic Insurance Premiums Tax Return or

(Rev. 12/15)

Health Care Center Tax Return

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.



I request a 12-month extension of time to March 1

of the succeeding calendar year,

to file a Connecticut domestic insurance

premiums tax return for calendar year above.



I request a 12-month extension of time to March 1

of the succeeding calendar year,

to file a Connecticut health care center 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 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

calendar year

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



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 207/207 HCC 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 207 207 HCC EXT\Form 207 207 HCC EXT 20151007.indd

Last Modified 2015107 02:59 PM

Form 207/207 Hcc Ext Draft - Application For Extension Of Time To File Domestic Insurance Premiums Tax Return Or Health Care Center Tax Return - 2015

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