Form 207f-5 - Insurance Premiums Tax Return Nonresident And Foreign Companies Initial Five-Year Return

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Department of Revenue Services
Form 207F-5
20
State of Connecticut
_ _
PO Box 2990
Insurance Premiums Tax Return
Hartford CT 06104-2990
Nonresident and Foreign Companies
(Rev. 12/14)
Initial Five-Year Return
Complete this return in blue or black ink only.
Company name
Connecticut Tax Registration Number
Address line 1
Date received (DRS use only)
Address line 2
Federal Employer ID Number (FEIN)
State
ZIP code
City, town, or post offi ce
Organized under the laws of
Enter fi rst year of fi ve-year period
and last year of fi ve-year period
_____________________________
_____________________________
Enter Connecticut Insurance License date
_____________________________
mm
dd
yyyy
1 Enter gross direct premiums received during the fi ve preceding calendar years.
See instructions.
1
00
2 Dividends paid to policyholders on direct business during the fi ve preceding calendar years
not including dividends paid on account of ownership of stock.
2
00
3 Net direct premiums received during the fi ve preceding calendar years from ocean marine
 3
insurance policies written on property located in this state.
00
4 Benefi t payments from group health insurance premiums to the extent allowed by
 4
Conn. Gen. Stat. §12-210a during the fi ve preceding calendar years.
00
 5
5 Total deductions: Add Lines 2, 3, and 4.
00
 6
6 Taxable premiums: Subtract Line 5 from Line 1.
00
 7
7 Multiply Line 6 by 1.75% (.0175).
00
 8
8 Taxes and other obligations on retaliatory basis: See instructions.
00
 9
9 Other obligations paid to Connecticut: See instructions.
00
 10
10 Retaliatory computation: Subtract Line 9 from Line 8.
00
11 Tax: Enter Line 7 or Line 10 amount, whichever is greater.
11
00
12 If late: penalty
(12a) $
plus interest
(12b) $
____________________________
_______________________________
See instructions.
12
00
13 Balance due with this return.

13
00
Make check payable to Commissioner of Revenue Services.
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 DRS is a fi ne of not more than $5,000, or 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
Print name of principal offi cer
Telephone number
Sign Here
(
)
Keep a copy
Email address of principal offi cer
of this return
for your
Paid preparer’s signature
Date
Preparer’s SSN or PTIN
records.
Firm’s name and address
FEIN

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