Form 207/207 F Ext - Application For Extension Of Time To File Insurance Premiums Tax Return January 2001

FORM 207/207 F EXT

STATE OF CONNECTICUT

207/207 F EXT

DEPARTMENT OF REVENUE SERVICES

2000

PO Box 2990

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Application for Extension of Time to File

Hartford CT 06104-2990

Insurance Premiums Tax Return

(Rev. 01/01)

Important! Please read instructions on reverse before completing this application.

Name of Company

CT Insurance Premiums Tax Reg. No.

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TAXPAYER

Address

Number and Street

PO Box

Date Received (FOR DEPARTMENT USE ONLY)

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(Please Type

or Print)

City, Town or Post Office

State

ZIP Code

Federal Employer Identification Number

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This is not an extension of time to pay tax – Penalties and interest may apply (See instructions)

I request a six-month extension of time, to September 1, 2001, to file a Connecticut insurance premiums tax return for calendar year 2000.

The reason for the Connecticut extension request is .........................................................................................................................

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–– You Will Be Notified Only if Your Request Is Denied ––

1. Total insurance premiums tax liability for 2000. (You may estimate this amount.)

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You must enter an amount on Line 1. If you do not expect to owe tax, enter zero (0) ..........

1

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2. 2000 Connecticut estimated tax payments and any overpayments credited to 2000 ............

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3. Insurance premiums tax balance due (Subtract Line 2 from Line 1). Pay in full with this form.

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If Line 2 is greater than Line 1, enter zero (0) ...........................................................................

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Make check payable to: Commissioner of Revenue Services.

Write the company’s Connecticut Insurance Premiums Tax Registration Number and “2000 Form 207/207 F EXT” on your

check.

Mail to:

Department of Revenue Services

PO Box 2990

Hartford CT 06104-2990

DECLARATION: I declare under the penalty of false statement that I have examined this application and, to the best of my knowledge and belief, it is true,

complete, and correct. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two thousand dollars, or both.)

Declaration of preparer (other than the taxpayer) is based on all information of which 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

Federal Employer Identification Number