Form 207f-5 - Insurance Premiums Tax Return - Nonresident And Foreign Companies, Initial Five-Year Return - 2006

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Department of Revenue Services
Form 207F-5
2006
PO Box 2990
Hartford CT 06104-2990
Insurance Premiums Tax Return
Nonresident and Foreign Companies
(Rev. 12/06)
Initial Five-Year Return
Complete this return in blue or black ink only.
Company Name
Connecticut Tax Registration Number
Date Received (DRS Use Only)
Address Line 1
Federal Employer ID Number (FEIN)
Address Line 2
Organized Under the Laws of
City, Town, or Post Office
State
ZIP Code
Enter first year of five-year period _____________________, and last year of five-year period _____________________
Enter Connecticut Insurance License date _________________________
mm
dd
yyyy
1 Enter gross direct premiums received during the five preceding calendar years.
(See instructions.)
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.)
8
00
9 Other obligations paid to Connecticut (See instructions.)
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
12 If late: penalty
(12a) $ _________________ plus interest
(12b) $ ____________________
12
00
(See instructions.)
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 the Department of Revenue Services (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
FEIN

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