Form 207f Ext - Application For Extension Of Time To File Insurance Premiums Tax Return Nonresident And Foreign Companies - 2012

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2012
Department of Revenue Services
Form 207F EXT
State of Connecticut
PO Box 2990
Application for Extension of Time to File
Hartford CT 06104-2990
Insurance Premiums Tax Return
(Rev. 01/13)
Nonresident and Foreign Companies
Read instructions on reverse before completing this application. Complete this application in blue or black ink only.
Name of company
Connecticut Tax Registration Number
Taxpayer
Address number and street
PO Box
Date received (DRS use only)
 
Please type
or print.
City, town, or post offi ce
State
ZIP code
Federal Employer ID Number (FEIN)
This is not an extension of time to pay tax. Penalties and interest may apply. See instructions.
request a 12-month extension of time to March 1, 2014 (or to March 1, 2015 for a second request), to fi le a Connecticut
I
nonresident and foreign insurance companies premiums tax return for calendar year 2012.
The reason for the Connecticut extension request is _________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
You will be notifi ed only if your request is denied.
1. Total insurance premiums tax liability for 2012: You may estimate this amount.
You must enter an amount on Line 1. If you do not expect to owe tax, enter zero “0.” .................. 1
00
2. 2012 Connecticut estimated tax payments and any overpayments credited to 2012 .................... 2
00
3. Insurance premiums tax balance due: Subtract Line 2 from Line 1. Pay in full with this
form. If Line 2 is greater than Line 1, enter zero “0.” ....................................................................
3
00
Pay Electronically
Mail paper return to:
Department of Revenue Services
Visit the Department of Revenue Services (DRS) Taxpayer
State of Connecticut
Service Center (TSC) at to pay
PO Box 2990
electronically.
Hartford CT 06104-2990
Make check payable to Commissioner of Revenue
Services.
Write the company’s Connecticut Tax Registration Number
and “2012 Form 207F EXT” on your check.
Declaration: I declare under 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 DRS is a fi ne of not more than $5,000, imprisonment for not more than fi ve 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 offi cer
Title
Date
Sign Here
Telephone number
Print name of principal offi cer
Keep a copy
(
)
of this return
Paid preparer’s signature
Date
Preparer’s SSN or PTIN
for your
records.
Firm name and address
FEIN

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