Department of Revenue Services
Form 207HCC
2003
State of Connecticut
Health Care Center Tax Return
PO Box 2990
Hartford CT 06104-2990
(Rev. 12/03)
Purpose: Each health care center authorized to conduct health care business in Connecticut must file this return on or before March 1, 2004, to report
its health care center tax liability for calendar year 2003.
Attach the following to this return:
•
The Statement of Revenue, Expenses, and Net Worth from the Annual Statement filed with the Insurance Department;
•
A copy of Schedule T;
•
2003 Form 207I, if applicable.
CT Health Care Center Tax Registration Number
Date Received (For Department Use Only)
Federal Employer Identification Number
Check if this is a new address
Check if this is an amended return
1 Total net direct subscriber charges less returned charges, including cancellations (See instructions)
1
00
Subscriber charges received from:
The State of Connecticut to provide health care coverage for state employees, retirees, or their dependents
2
00
2
The State of Connecticut to provide health care coverage for retired teachers, their spouses, or their surviving
3
3
00
spouses covered by plans offered by the State Teachers’ Retirement System
Connecticut municipalities to provide health coverage for municipal employees
4
00
4
Nonprofit organizations to provide health coverage for employees and their dependents
5
00
5
The federal government to provide coverage for Medicare patients
6
00
6
The State of Connecticut to provide health care coverage for Medicaid recipients
7
00
7
State of Connecticut to provide health care coverage for eligible beneficiaries under the HUSKY Plan,
8
8
00
Part A; HUSKY Plan, Part B; or the HUSKY Plus Programs
The State of Connecticut to provide health care coverage for recipients of state administered general
9
9
00
assistance
10 The federal Employees Health Benefits Fund to provide coverage for qualified enrollees
10
00
11 Individuals eligible for a health coverage tax credit and their dependents
11
00
12 Total deductions (Add Lines 2 through 11)
12
00
13 Subtract Line 12 from Line 1
13
00
14 Health care center tax: Multiply Line 13 by 1.75% (.0175)
14
00
15a General business tax credits (See instructions on back)
00
15a
15b Multiply Line 14 by 70% (.70)
15b
00
15c Enter Line 15a or Line 15b, whichever is less
15c
00
16 Subtract Line 15c from Line 14 (If less than zero, enter zero (0))
16
00
17 Overpayment applied from prior year
17
00
18 Payments made with estimated tax payment coupons (Forms 207HCC ESA, ESB, ESC, and ESD)
18
00
19 Payments made with extension request (Form 207HCC EXT) (See instructions on back)
19
00
20 Total prior payments (Add Lines 17, 18, and 19)
20
00
21 If Line 20 is greater than Line 16, enter amount overpaid
21
00
00
22 Amount to be: Credited to 2004 estimated tax (22a) $_______________ Refunded (22b)$______________
22
23 If Line 16 is greater than Line 20, enter amount owed
23
00
00
24 If Late: penalty (24a) $__________________ plus interest (24b) $__________________(See instructions)
24
25
00
25 Interest on underpayment of estimated tax (Attach Form 207
I
) (See instructions on back)
26 Balance due with this return (Make check payable to: Commissioner of Revenue Services)
26
00
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 that the penalty for willfully delivering a false return or document 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
Date
Preparer's PTIN or SSN
for your
records
Firm Name and Address
Federal Employer Identification Number