Looking for a Ct Tax Forms And Templates? Download it for free!

2004

Department of Revenue Services

Form 207F

State of Connecticut

PO Box 2990

Insurance Premiums Tax Return

Hartford CT 06104-2990

Nonresident and Foreign Companies

(Rev. 5/05)

General Information:

A. Return Status:

Amended

Final

B. Change of:

Address

Domicile

Enter new domicile: _____________________________________________________

C. If this is a short period, enter period covered by this return: _____________________________________________________________________

D. If this is a final return, has the insurance company:

Merged/Reorganized ______________________________________________________

(Enter survivor’s Connecticut Tax Registration Number)

E. The insurance company is currently under:

Receivership

Rehabilitation

CT Insurance Premiums Tax Registration No.

Please

make

changes to

Date Received (For Department Use Only)

your name

and

Federal Employer Identification Number

address if

shown

Organized Under the Laws of

incorrectly

Enter gross direct premiums received during the calendar year (See instructions on back)

Dividends paid to policyholders on direct business, not including dividends paid on account of ownership of stock

Net direct premiums received during the year from ocean marine insurance policies written on property located in

this state

Benefit payments from group health insurance premiums to the extent allowed by Conn. Gen. Stat. §12-210a

Total deductions (Add Lines 2, 3, and 4)

Taxable premiums (Subtract Line 5 from Line 1)

Multiply Line 6 by 1.75% (.0175)

Taxes and other obligations on retaliatory basis (See instructions on back)

Other obligations paid to Connecticut (See instructions on back)

Retaliatory computation (Subtract Line 9 from Line 8)

Tax (Enter Line 7 or Line 10 amount, whichever is greater)

Multiply Line 11 by 70% (.70) (See instructions on back)

General business tax credits (Attach CT-1120K if applicable. See instructions on back)

Enter Line 12 or Line 13, whichever is less

Enter CIGA assessment credit (See instructions on back)

Enter CLHIGA assessment credit (See instructions on back)

Total credits (Add Line 14, 15, and 16)

Balance of tax payable. Subtract Line 17 from Line 11 (If less than zero, enter zero (0))

Overpayment applied from prior year

Payments made with estimated tax payment coupons (Forms 207F ESA, ESB, ESC, and ESD)

Payments made with extension request (Form 207F EXT)

Total prior payments (Add Lines 19, 20, and 21)

If Line 22 is greater than Line 18, enter amount overpaid

(24a) $_________________ Refunded

Amount to be: Credited to 2005 estimated tax

(24b) $________________ 24

If Line 18 is greater than Line 22, enter amount owed

If late: penalty (26a) $______________________ plus interest (26b) $__________________(See instructions)

)

Interest on underpayment of estimated tax (Attach Form 207I. See Instructions on back

Balance due with this return (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 to DRS is a fine of not more than $5,000,

or imprisonment for not more than five 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 Officer

Title

Date

Sign Here

Keep a copy

Print Name of Principal Officer

Telephone Number

of this return

(

)

for your