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

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Department of Revenue Services
Form 207C EXT
207C EXT
State of Connecticut
20
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.
00
If you do not expect to owe tax, enter zero “0.” ............................................................................. 1
00
2. Any overpayments applied to the calendar year. ........................................................................... 2
3. Balance due: Subtract Line 2 from Line 1. Pay in full with this form.
00
If Line 2 is greater than Line 1, enter zero “0.” .............................................................................
3
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

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