Form 211 Ccv - Certified Competitive Video Service Companies Gross Earnings Tax Return Form
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1
2Department of Revenue Services
Form 211 CCV
State of Connecticut
PO Box 2990
Certified Competitive Video Service Companies
Hartford CT 06104-2990
Gross Earnings Tax Return
(New 12/07)
Complete this return in blue or black ink only. Read instructions on back before completing this return.
When to File
Form 211 CCV is due on or before the last day of April, July, October, and January for the prior calendar quarter, even if no tax is due.
If the due date falls on a Saturday, Sunday, or legal holiday, the next business day is the due date.
Name of Company
Connecticut Tax Registration Number
Taxpayer
For Calendar Quarter Ended
Address
Number and Street
PO Box
Type
Federal Employer ID Number (FEIN)
or
City, Town, or Post Office
State
ZIP Code
Print
Date Received (DRS Use Only)
Amended Return
Change of Address
1. Total gross earnings from transmitting video programming by Certified
Video Providers to subscribers, both inside and outside Connecticut
1.
00
2. Average number of subscribers in Connecticut during the calendar
00
quarter: See instructions.
2.
3. Average number of subscribers, both inside and outside Connecticut,
during the calendar quarter: See instructions.
3.
00
Decimal Notation
4. Divide Line 2 by Line 3; carry to six decimal places.
4.
.
5. Multiply Line 1 by Line 4.
5.
00
6. Tax: Multiply Line 5 by 5% (.05).
6.
00
7. General business tax credit(s): Attach Form CT-1120K, Business Tax
7.
00
Credit Summary. See instructions on back.
8. Subtract Line 7 from Line 6. If less than zero, enter “0.”
8.
00
9. If late, enter penalty. See instructions.
9.
00
10. If late, enter interest. See instructions.
10.
00
11. Total Amount Due: Add Lines 8, 9, and 10.
11.
00
Make check payable to: Commissioner of Revenue Services
Mail to: Department of Revenue Services, State of Connecticut, PO Box 2990, Hartford CT 06104-2990
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 Treasurer (or authorized agent or officer)
Date
Telephone Number
(
)
Sign Here
Print name of Treasurer (or authorized agent or officer)
Title
Keep a copy
of this return
Paid Preparer’s Signature
Date
Preparer’s SSN or PTIN
for your
records.
Firm’s Name and Address
FEIN
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