Form 207 - Insurance Premiums Tax Return Domestic Companies

Department of Revenue Services

Form 207

2004

State of Connecticut

PO Box 2990

Insurance Premiums Tax Return

Hartford CT 06104-2990

Domestic Companies

(Rev. 5/05)

General Information:

A. Return Status:

Amended

Final

B. Change of:

Address

Domicile

Enter new domicile: ____________________________________________________________

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

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

Merged/Reorganized ______________________________________________________

(Enter survivor’s Connecticut Tax Registration Number)

E. The insurance company is currently under:

Receivership

Rehabilitation

Please

make

CT Insurance Premiums Tax Registration No.

changes to

your name

and

Date Received (For Department Use Only)

address if

shown

incorrectly

Federal Employer Identification Number

1 Gross direct premiums received during the calendar year (See instructions on back)

2 Dividends paid to policyholders on direct business, not including dividends paid on account of the ownership of stock

3 Taxable premiums (Subtract Line 2 from Line 1)

4 Tax: Multiply Line 3 by 1.75% (.0175)

5 Multiply Line 4 by 70% (.70) (See instructions on back)

6 Insurance Department assessment credit (See instructions on back)

7 General business tax credits (Attach CT-1120K if applicable. See instructions on back)

8 Add Line 6 and Line 7

9 Enter Line 5 or Line 8, whichever is less

10 Enter your CIGA assessment credit (See instructions on back)

11 Enter your CLHIGA assessment credit (See instructions on back)

12 Add Lines 9, 10, and 11

13 Balance of tax payable. Subtract Line 12 from Line 4 (If less than zero, enter zero (0))

14 Overpayment applied from prior year

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

16 Payments made with extension request (Form 207/207HCC EXT)

17 Total prior payments (Add Lines 14, 15, and 16)

18 If Line 17 is greater than Line 13, enter amount overpaid

(19a) $_________________ Refunded

19 Amount to be: Credited to 2005 estimated tax

(19b) $__________________ 19

20 If Line 13 is greater than Line 17, enter amount owed

21 If late: penalty (21a) $ ___________________ plus interest

(21b) $ ___________________ (See instructions)

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

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

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 to 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