Form Ct-33-C - Captive Insurance Company Franchise Tax Return - 2012 Page 2
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1
2Page 2 of 2 CT-33-C (2012)
Composition of prepayments on line 14 (
)
see instructions
Date paid
Amount
23 Mandatory first installment .........................................................................................
23
24a Second installment from Form CT-400 ....................................................................... 24a
24b Third installment from Form CT-400 ........................................................................... 24b
24c Fourth installment from Form CT-400 ......................................................................... 24c
25 Payment with extension request
.............................................
25
(from Form CT-5, line 5)
26 Overpayment credited from prior years ...........................................................................................
26
27 Total prepayments
..................................................
27
(add lines 23 through 26; enter here and on line 14)
Have you been audited by the Internal Revenue Service in the past 5 years? ............................................................ Yes
No
(if Yes, list years)
Designee’s name
Designee’s phone number
(print)
Third – party
Yes
No
(
)
designee
Designee’s e-mail address
(see instructions)
PIN
Certification: I certify that this return and any attachments are to the best of my knowledge and belief true, correct, and complete.
Printed name of authorized person
Signature of authorized person
Official title
Authorized
person
E-mail address of authorized person
Telephone number
Date
(
)
Firm’s name
Firm’s EIN
Preparer’s PTIN or SSN
Paid
(or yours if self-employed)
preparer
Signature of individual preparing this return
Address
City
State
ZIP code
use
only
E-mail address of individual preparing this return
Preparer’s NYTPRIN
Date
(see instr.)
Attach a copy of your complete federal return and a copy of your New York Captive Insurance Company Annual Statement as filed
with the New York State Department of Financial Services.
See instructions for where to file.
431002120094
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