Form 211 Csv - Cable, Satellite, And Video Gross Earnings Tax Return Form
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1
2Department of Revenue Services
Form 211 CSV
State of Connecticut
Cable, Satellite, and Video
PO Box 2990
Hartford CT 06104-2990
Gross Earnings Tax Return
(Rev. 02/08)
Complete this return in blue or black ink only. Read instructions on back before completing this return.
When to File
Form 211 CSV is due on or before the last day of April, July, October, and January, for the preceding 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. Enter amount from Form 211 SATV, Line 5, if Form 211 SATV was filed.
1.
00
2. Enter amount from Form 211 CATV, Line 3, if Form 211 CATV was filed.
2.
00
3. Enter amount from Form 211 CCV, Line 5, if Form 211 CCV was filed.
3.
00
4. Add Lines 1, 2, and 3 and enter the total.
4.
00
5. Tax: Multiply Line 4 by 1/2% (.005).
5.
00
6. If late, enter penalty. See instructions.
6.
00
7. If late, enter interest. See instructions.
7.
00
8. Total amount due: Add Lines 5, 6, and 7.
8.
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
(
)
Keep a copy
Print name of Treasurer (or authorized agent or officer)
Title
of this return
for your
Paid Preparer’s Signature
Date
Preparer’s SSN or PTIN
records.
Firm’s Name and Address
FEIN
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