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Department of Revenue Services

Form 207C EXT

207C EXT

State of Connecticut

PO Box 2990



___

Application for Extension of Time to File

Hartford CT 06104-2990

Captive Insurance Premiums Tax Return

(Rev. 12/15)

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.

I request a 12-month extension of time to March 1 of the succeeding calendar year, to ﬁ le a captive insurance premiums tax

return for calendar year above.

The reason for the Connecticut extension request is: __________________________________________________________________

____________________________________________________________________________________________________________

You will be notiﬁ ed only if your request is denied.

1. Total tax liability for the calendar year: 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 applied to the calendar year. ........................................................................... 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,

the calendar year of the return, and “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 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

Print name of principal ofﬁ cer

Telephone number

Keep a copy

(

)

of this return

for your

Paid preparer’s signature

Date

Preparer’s SSN or PTIN

records.

Firm name and address

FEIN

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

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