Form 207 Hcc - Health Care Center Tax Return

Form 207HCC Instructions

General Instructions

Line 18: Enter payment made with Form 207/207 HCC EXT, Application

for Extension of Time to File Domestic Insurance Premiums Tax Return

Complete this return in blue or black ink only.

or Health Care Center Tax Return. To request an extension of time to

Due Date: This return is due on or before March 1, 2015, for health care

ﬁ le Form 207 HCC, you must ﬁ le Form 207/207 HCC EXT and pay all

center tax liability for calendar year 2014.

the tax you expect to owe on or before March 1, 2015.

Attachments: Attach the following to this return:

Line 19: If Line 15 is greater than Line 19, subtract Line 19 from Line 15.

• The Statement of Revenue and Expenses from the Annual Statement

This is the amount of tax you owe.

ﬁ led with the Connecticut Insurance Department;

Line 21: Add Line 21a and Line 21b. Your election to credit your

• A copy of Schedule T;

overpayment to your 2015 estimated health care center tax or to

• 2014 Form 207I, if applicable; and

have your overpayment refunded to you is irrevocable.

• 2014 Form CT-207K, if applicable.

Line 21a: Enter the amount of overpayment you want applied to your

2015 estimated health care center tax. The overpayment will be treated

Rounding Off to Whole Dollars: You must round off cents to the nearest

as an estimated tax payment made on the ﬁ fteenth day of March of

whole dollar on your return and schedules.

the calendar year it is being applied to if this return is ﬁ led on time or

Filing an Amended Return: To ﬁ le an amended return, complete a new

if the tax return is ﬁ led within the extension period if a timely request

Form 207 HCC using the correct ﬁ gures and information for the reporting

for extension was ﬁ led. A request to apply an overpayment to the

period. Enter the amount paid with the original return on Line 18.

following year is irrevocable.

Line Instructions

Line 21b: Enter the amount of overpayment you want refunded to you.

Line 1: Enter total net direct subscriber charges received during calendar

Lines 21c through 21e: Get your refund faster by choosing direct

year 2014 on any new or renewal contract.

deposit. Complete Lines 21c, 21d, and 21e to have your refund directly

deposited into your checking or savings account.

Line 2: Enter net direct subscriber charges received during calendar year

2014 on any contract or policy entered into with the State of Connecticut

Enter your nine-digit bank routing number

No. 101

Name of Depositor

Date

Street Address

to provide health care coverage to state employees, retirees, or their

and your bank account number in Lines

City, State, Zip Code

Pay to the

Order of

dependents.

21d and 21e. Your bank routing number is

the ﬁ rst nine-digit number printed on your

Line 3: Enter net direct subscriber charges received during calendar year

Name of your Bank

Street Address

City, State, Zip Code

check or savings withdrawal slip. Your bank

2014 on any contract or policy entered into with the State of Connecticut

092125789

091 025 025413

0101

account number generally follows the bank

on or after February 1, 2000, to provide health care coverage to retired

Routing Number

Account Number

routing number. Do not include the check

teachers, their spouses, or their surviving spouses covered by plans

number as part of your account number. Bank account numbers can be

offered by the State Teachers’ Retirement System.

up to 17 characters. If any of the bank information you supply for direct

Line 4: Enter net direct subscriber charges received during calendar

deposit does not match or you close the applicable bank account prior

year 2014 on any contract or policy entered into on or after July 1,

to the deposit of the refund, your refund will automatically be mailed.

2001, to provide health care coverage for employees of a Connecticut

Line 21f: Federal banking rules require DRS to request information

municipality and their dependents under a plan procured under Conn.

about foreign bank accounts when the taxpayer requests the direct

Gen. Stat. §5-259(i).

deposit of a refund into a bank account. If the refund is to be deposited

Line 5: Enter net direct subscriber charges received during calendar year

in a bank outside of the United States, DRS will mail the refund.

2014 on any contract or policy entered into: (A) On or after July 1, 2001,

Line 23a: Late Payment Penalty: Multiply Line 22 by 10%. Enter the

to provide health care coverage for employees of a Connecticut nonproﬁ t

result or $50, whichever is greater.

organization and their dependents under a plan procured under Conn.

Gen. Stat. §5-259(i); and (B) On or after July 1, 2005, to provide health

Line 23b: Multiply Line 22 by 1% per month or fraction of a month from

care coverage for employees of a community action agency and their

the original due date of the return to the date of payment.

dependents under a plan procured under Conn. Gen. Stat. §5-259(i).

Line 24: If estimated tax was underpaid, complete and attach Form

Line 6: Enter net direct subscriber charges received during calendar

207I, Underpayment of Estimated Insurance Premiums Tax or Health

year 2014 from the federal government to provide health care coverage

Care Center Tax, and enter the amount from Line 22 of Form 207I.

for Medicare patients.

Line 25: Add the amounts from Lines 22, 23, and 24.

Line 7: Enter net direct subscriber charges received during calendar year

Make check payable to Commissioner of Revenue Services. Write

2014 from a contract or policy entered into with the State of Connecticut

“2014 Form 207 HCC” and your Connecticut Tax Registration Number

to provide health care coverage to Medicaid recipients.

on the front of your check. DRS may submit your check to your bank

Line 8: Enter net direct subscriber charges received during calendar

electronically. Mail to the address on the front of this return.

year 2014 from any contract or policy entered into with the State of

Signature: The treasurer of the company, or a principal ofﬁ cer of the

Connecticut on or after April 1, 1998, to provide health care coverage

company, must sign Form 207 HCC.

to eligible beneﬁ ciaries under the HUSKY Plan, Part A; HUSKY Plan,

Paid Preparer Signature: A paid preparer must sign and date

Part B; or the HUSKY Plus programs.

Form 207 HCC. Paid preparers must also enter their Social Security

Line 9: Enter net direct subscriber charges received during calendar

Number (SSN) or Preparer Tax Identiﬁ cation Number (PTIN) and their

year 2014 from the federal Employee Health Beneﬁ ts Fund to provide

ﬁ rm’s Federal Employer ID Number (FEIN) in the spaces provided.

health care coverage for U.S. government employees, retired U.S.

Pay Electronically: Visit to make a

government employees, certain former U.S. government employees

direct tax payment. Using this option authorizes DRS

and eligible members of their families.

to electronically withdraw a payment from your bank

Line 10: Enter net direct subscriber charges received during calendar

account (checking or savings) on a date you select up to the due date.

year 2014 on any contract or policy entered into: (A) On or after July 1,

If you pay electronically, you must still ﬁ le your return on or before the

2003, to provide health care coverage for individuals eligible for a health

due date.

coverage tax credit and their dependents under a plan procured under

For More Information: Call DRS during business hours, Monday

Conn. Gen. Stat. §5-259(i); and (B) On or after July 1, 2005, to provide

through Friday:

health care coverage for individuals eligible for a retirement beneﬁ t

• 1-800-382-9463 (Connecticut calls outside the Greater Hartford calling

from the Connecticut municipal employees’ retirement system and their

area only); or

dependents under a plan procured under Conn. Gen. Stat. §5-259(i).

• 860-297-5962 (from anywhere).

Line 14: If your company is claiming Connecticut tax credits, Form

TTY, TDD, and Text Telephone users only may transmit inquiries

CT-207K, Insurance/Health Care Tax Credit Schedule, must be

completed and attached to this return.

anytime by calling 860-297-4911.

Forms and Publications: Visit the DRS website at

Line 17: Enter estimated payments made with Forms 207 HCC ESA,

to download and print Connecticut tax forms and publications.

ESB, ESC, and ESD.

Form 207 HCC (Rev. 12/14)

Form 207 Hcc - Health Care Center Tax Return - 2014 Page 2

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