Form 207i - Underpayment Of Estimated Insurance Premiums Tax Or Health Care Center Tax - 2011

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2011
Department of Revenue Services
Form 207I
Calendar Year
State of Connecticut
PO Box 2990
Underpayment of Estimated
Hartford CT 06104-2990
Insurance Premiums Tax or Health Care Center Tax
(Rev. 12/11)
Company name
Connecticut Tax Registration Number
See instructions on reverse side before completing this form.
Complete this form in blue or black ink only.
Part I: Required Annual Payment
1. From the 2011 returns, enter the amount shown on Form 207, Line 9; Form 207F, Line 16;
or Form 207 HCC, Line 15. If the amount is less than $1,000, do not complete this form. ...........................
1
2. Multiply Line 1 by 90% (.90). ...........................................................................................................................
2
3. From the 2010 returns, enter the amount shown on Form 207, Line 13; Form 207F, Line 18; ....................
or Form 207 HCC, Line 16. ............................................................................................................................
3
4. Enter the lesser of Line 2 or Line 3. ................................................................................................................
4
Part II: Calculate Your Underpayment and Interest for Each Calendar Quarter
A
B
C
D
3-15-2011
6-15-2011
9-15-2011
12-15-2011
5. Installment due dates ..................................................................................
5
6. Enter the amount from Line 4 in Columns A through D. .............................
6
.30
.30
.20
.20
7. Estimated installment rate ...........................................................................
7
8. Multiply Line 6 by Line 7. ............................................................................
8
9. Enter payments made or credits received on or before the installment
due date. .....................................................................................................
9
10. Subtract Line 9 from Line 8. If the result is less than or equal to zero,
enter “0.” See instructions if credit is established. ...................................... 10
11. Enter date of additional payment or credit received after the installment
mm
dd
yy mm
dd
yy mm
dd
yy mm
dd
yy
due date. If no additional payment or credit, enter earlier of due date of
/ /
/ /
/ /
/ /
annual return or fi ling date of annual return. ...............................................
11
12. Enter whichever is less: the number of months from the date on Line 5,
Columns A through D, to the payment date shown on Line 11, Columns A
through D; or 12 months for ESA; 9 months for ESB; 6 months for ESC;
3 months for ESD. ....................................................................................... 12
13. Multiply the number of months on Line 12 by 1% (.01). ............................. 13
14. Interest due: Multiply Line 10 by Line 13. ................................................... 14
15. Enter the amount of payment made or credit received on date shown on
Line 11, Columns A through D. ................................................................... 15
16. Subtract Line 15 from Line 10. .................................................................... 16
17. Enter the date of the next additional payment or credit that meets the
mm
dd
yy mm
dd
yy mm
dd
yy mm
dd
yy
balance on Line 16, Columns A through D. If no additional payment or
/ /
/ /
/ /
/ /
credit, enter due date of annual return. ....................................................... 17
18. Enter the number of months from Line 11, Columns A through D, to date
shown on Line 17, Columns A through D. ................................................... 18
19. Multiply the number of months on Line 18 by 1% (.01). ............................. 19
20. Interest due: Multiply Line 16 by Line 19. ................................................... 20
21. Total interest due: Add Line 14 and Line 20. .............................................. 21
22. Add Line 21, Columns A through D, and enter here and on 2011 Form 207, Line 18;
2011 Form 207F, Line 25; or 2011 Form 207 HCC, Line 24. .......................................................................... 22

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