Form 207f-5 - Insurance Premiums Tax Return Nonresident And Foreign Companies Initial Five-Year Return - 2004

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2004
Department of Revenue Services
Form 207F-5
State of Connecticut
Insurance Premiums Tax Return
PO Box 2990
Hartford CT 06104-2990
Nonresident and Foreign Companies
(New 5/05)
Initial Five-Year Return
Company Name
CT Insurance Premiums Tax Registration No.
Address Line 1
Date Received (For Department Use Only)
Address Line 2
Federal Employer Identification Number
City, Town, or Post Office
State
ZIP Code
Organized Under the Laws of
_________________, _____,
___________________, ______
Enter First Year of Five-Year Period
and Last Year of Five-Year Period
1
Enter gross direct premiums received during the five preceding calendar years
(See instructions on back)
1
00
2
Dividends paid to policyholders on direct business during the five preceding calendar years
not including dividends paid on account of ownership of stock
2
00
3
Net direct premiums received during the five preceding calendar years from ocean marine
insurance policies written on property located in this state
3
00
4
Benefit payments from group health insurance premiums to the extent allowed by
Conn. Gen. Stat. §12-210a during the five preceding calendar years
4
00
5
Total deductions (Add Lines 2, 3, and 4)
5
00
6
Taxable premiums (Subtract Line 5 from Line 1)
6
00
7
Multiply Line 6 by 1.75% (.0175)
7
00
8
Taxes and other obligations on retaliatory basis (See instructions on back)
8
00
9
Other obligations paid to Connecticut (See instructions on back)
9
00
10
Retaliatory computation (Subtract Line 9 from Line 8)
10
00
11
Tax (Enter Line 7 or Line 10 amount, whichever is greater)
11
00
.00
.00
12
If late: penalty
(12a) $______________________ plus interest
(12b) $__________________
12
00
(See instructions on back)
13
Balance due with this return (Make check payable to: Commissioner of Revenue Services)
13
00
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
Print Name of Principal Officer
Telephone Number
Keep a copy
(
)
of this return
Paid Preparer’s Signature
Date
Preparer’s SSN or PTIN
for your
records
Firm Name and Address
Federal Employer Identification Number

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