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Form 207C EXT

207C EXT

Department of Revenue Services

State of Connecticut

2012

PO Box 2990

Application for Extension of Time to File



Hartford CT 06104-2990

Captive Insurance Premiums Tax Return

(New 01/13)

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 office

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.

I request a 12-month extension of time to March 1, 2014, to file a captive insurance premiums tax return for calendar year 2012.

The reason for the Connecticut extension request is: __________________________________________________________________

____________________________________________________________________________________________________________

You will be notified only if your request is denied.

1. Total tax liability for 2012: You may estimate this amount. Minimum tax $7,500.00.

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

2. Any overpayments credited to 2012 ............................................................................................... 2

3. 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.” .............................................................................



Pay Electronically

Mail paper return to:

Department of Revenue Services

Visit the Department of Revenue Services (DRS)

State of Connecticut

Taxpayer Service Center (TSC) at

PO Box 2990

to pay electronically.

Hartford CT 06104-2990

Make check payable to: Commissioner of Revenue

Services.

Write the company’s Connecticut Tax Registration Number

and “2012 Form 207C 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 the DRS is a fine of not more than $5,000, 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 SSN or PTIN

for your

records.

Firm name and address

FEIN

Form 207c Ext - Application For Extension Of Time To File Captive Insurance Premiums Tax Return - 2012

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