Form Ct-33-C - Captive Insurance Company Franchise Tax Return

CT-33-C (1999) (back)

Composition of prepayments on line 14

Date paid

Amount

23 Mandatory first installment from previous period ................................................ 23

24 CT-400 installments .............................................................................................

24 (1)

(2)

(3)

25 Payment with extension request

...................................... 25

(from Form CT-5, line 5)

26 Credit from prior years ...................................................................................................................... 26

27 Total prepayments

................................................. 27

(add lines 23 through 26; enter here and on line 14)

Have you been audited by the Internal Revenue Service in the past 5 years? ( if Yes list years )

Yes

Certification. I certify that this return and any attachments are to the best of my knowledge and belief true, correct, and complete.

Signature of elected officer or authorized person

Official title

Date

Firm’s name

ID number

Date

(or yours if self-employed)

Address

Signature of individual preparing this return

Attach a copy of your complete federal return, a copy of your Annual Report of Premiums as filed with the New York State Insurance

Department, and copies of the following schedules from your Annual Statement: Balance Sheet , the Analysis of Assets Exhibit , and the

Summary by Country portion of Schedule D .

Mail returns to: NYS CORPORATION TAX, PROCESSING UNIT, PO BOX 22038, ALBANY NY 12201-2038

Private delivery services

If you choose, you may use a private delivery service, instead of the U.S. Postal Service, to file your return. However, if, at a later date, you

need to establish the date you filed your return, you cannot use the date recorded by a private delivery service unless you used a delivery

service that has been designated by the U.S. Secretary of the Treasury or the Commissioner of Taxation and Finance. (Currently designated

delivery services are listed in Publication 55, Designated Private Delivery Services. See Need help? below for information on ordering forms

and publications.) If you use any private delivery service, whether it is a designated service or not, address your return to: State Processing

Center, 431C Broadway, Albany NY 12204-4836.

Need help?

Hotline for the hearing and speech impaired:

Telephone assistance is available from 8:30 a.m. to

1 800 634-2110 from 8:30 a.m. to 4:25 p.m. (eastern time),

4:25 p.m. (eastern time), Monday through Friday.

Monday through Friday. If you do not own a

telecommunications device for the deaf (TDD), check with

For business tax information, call the

independent living centers or community action programs

New York State Business Tax

to find out where machines are available for public use.

Information Center:

1 800 972-1233

Persons with disabilities: In compliance with the

For general information:

1 800 225-5829

Americans with Disabilities Act, we will ensure that our

To order forms and publications:

1 800 462-8100

lobbies, offices, meeting rooms, and other facilities are

accessible to persons with disabilities. If you have

From areas outside the U.S. and

questions about special accommodations for persons with

outside Canada:

(518) 485-6800

disabilities, please call 1 800 225-5829.

Fax-on-demand forms: Forms are

If you need to write, address your letter to:

available 24 hours a day,

1 800 748-3676

7 days a week.

NYS TAX DEPARTMENT

TAXPAYER ASSISTANCE BUREAU

TAXPAYER CORRESPONDENCE

Internet access:

W A HARRIMAN CAMPUS

ALBANY NY 12227

Form Ct-33-C - Captive Insurance Company Franchise Tax Return - 1999 Page 2

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