Form 207hcc - Health Care Center Tax Return - 2004 printable pdf download

Department of Revenue Services

Form 207HCC

2004

State of Connecticut

Health Care Center Tax Return

PO Box 2990

Hartford CT 06104-2990

(Rev. 5/05)

General Information:

A. Return Status:

Amended

Final

B. Change of:

Address

C. If this is a short period, enter period covered by this return: ______________________________________________________________________

D. If this is a final return, has the insurance company:

Merged/Reorganized

___________________________________________________

(Enter Survivor’s Connecticut Tax Registration Number)

E. The health care center is currently under:

Receivership

Rehabilitation

Please

CT Health Care Center Tax Registration Number

make

changes to

your name

Date Received (For Department Use Only)

and

address if

shown

Federal Employer Identification Number

incorrectly

1 Total net direct subscriber charges less returned charges, including cancellations (See instructions)

Subscriber charges received from:

2 The State of Connecticut to provide health care coverage for state employees, retirees, or their dependents

The State of Connecticut to provide health care coverage for retired teachers, their spouses, or their surviving

spouses covered by plans offered by the State Teachers’ Retirement System

4 Connecticut municipalities to provide health coverage for municipal employees

5 Nonprofit organizations to provide health coverage for employees and their dependents

6 The federal government to provide coverage for Medicare patients

7 The State of Connecticut to provide health care coverage for Medicaid recipients

State of Connecticut to provide health care coverage for eligible beneficiaries under the HUSKY Plan,

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

assistance

10 The federal Employees Health Benefits Fund to provide coverage for qualified enrollees

11 Individuals eligible for a health coverage tax credit and their dependents

12 Total deductions (Add Lines 2 through 11)

13 Subtract Line 12 from Line 1

14 Health care center tax: Multiply Line 13 by 1.75% (.0175)

15a General business tax credits (Attach CT-1120K if applicable. See instructions on back)

15a

15b Multiply Line 14 by 70% (.70)

15b

15c Enter Line 15a or Line 15b, whichever is less

15c

16 Balance of tax payable. Subtract Line 15c from Line 14 (If less than zero, enter zero (0))

17 Enter prior year overpayment(s)

18 Payments made with estimated tax payment coupons (Forms 207HCC ESA, ESB, ESC, and ESD)

19 Payments made with extension request (Form 207/207HCC EXT) (See amended returns on back)

20 Total prior payments (Add Lines 17, 18, and 19)

21 If Line 20 is greater than Line 16, enter amount overpaid

22 Amount to be: Credited to 2005 estimated tax (22a) $_______________ Refunded (22b)$______________

23 If Line 16 is greater than Line 20, enter amount owed

24 If Late: penalty (24a) $__________________ plus interest (24b) $__________________(See instructions)

25 Interest on underpayment of estimated tax (Attach Form 207I. See instructions on back)

26 Balance due with this return (Make check payable to: Commissioner of Revenue Services)

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 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