Form 207 - Insurance Premiums Tax Return Domestic Companies
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12012
Form 207
Department of Revenue Services
State of Connecticut
PO Box 2990
Insurance Premiums Tax Return
Hartford CT 06104-2990
Domestic Companies
(Rev. 12/12)
Complete this return in blue or black ink only.
General Information
A.
Check if this is an amended return.
B. Change of:
Address
Domicile, enter new domicile:
________________________________________________________________
C. If this is a short period, enter period covered by this return:
________________________________________________________________________
D. If this is a final return, is the insurance company:
No longer licensed in Connecticut; out of business
Merged/reorganized
______________________________________________________
Enter survivor’s CT Tax Registration No.
E. The insurance company is currently in:
Receivership
Rehabilitation
Name of company
Connecticut Tax Registration Number
Taxpayer
Address
Number and street
PO Box
Date received (DRS use only)
Please
type
or print.
(FEIN)
City or town
State
ZIP code
Federal Employer ID Number
1. Gross direct premiums received during the calendar year: See instructions. .................................................
1
00
2. Dividends paid: See instructions. ....................................................................................................................
2
00
3. Taxable premiums: Subtract Line 2 from Line 1. .............................................................................................
3
00
4. Tax: Multiply Line 3 by 1.75% (.0175). ............................................................................................................
4
00
5. Enter amount from Form CT-207K, Part 4, Line 32, Column C. ......................................................................
5
00
6. Enter your CIGA assessment credit. See instructions. ....................................................................................
6
00
7. Enter your CLHIGA assessment credit. See instructions. ...............................................................................
7
00
8. Add Lines 5, 6, and 7. ......................................................................................................................................
8
00
9. Net tax: Subtract Line 8 from Line 4. If less than zero, enter zero “0.” ...........................................................
9
00
10. Overpayment applied from prior year ..............................................................................................................
10
00
11. Payments made with estimated tax payment coupons Forms 207 ESA, ESB, ESC, and ESD ....................
11
00
12. Payments made with extension request Form 207/207 HCC EXT .................................................................
12
00
13. Total prior payments: Add Lines 10, 11, and 12. .............................................................................................
13
00
14. If Line 13 is greater than Line 9, enter amount overpaid. ................................................................................
14
00
15. Amount to be: credited to 2013 estimated tax
(15a) $ _____________refunded
(15b) $ ______________
15
00
For faster refund, use Direct Deposit by completing Lines 15c, 15d, and 15e.
15c. Checking
Savings
15d. Routing number
15e. Account number
15f. Will this refund go to a bank account outside the U.S.?
Yes
16. If Line 9 is greater than Line 13, enter amount owed. .....................................................................................
16
00
17. If late: penalty
(17a) $__________________ plus interest
(17b) $ __________________ See instructions.
17
00
I
18. Interest on underpayment of estimated tax: Attach Form 207
. See instructions. ..........................................
18
00
19. Balance due with this return. Make check payable to Commissioner of Revenue Services. ......................
19
00
Visit the Department of Revenue Services (DRS) website at to pay electronically.
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 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
Paid preparer’s signature
Date
Preparer’s SSN or PTIN
for your
records.
Firm name and address
FEIN
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