Form 207 Hcc - Health Care Center Tax Return - 2014 printable pdf download

Department of Revenue Services

2014

Form 207 HCC

State of Connecticut

PO Box 2990

Health Care Center Tax Return

Hartford CT 06104-2990

(Rev. 12/14)

Complete this return in blue or black ink only.

 

General Information

Check if this is an amended return.



 Address

Domicile, enter new domicile:

B. Change of:

________________________________________________________________

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

________________________________________________________________________



D. If this is a ﬁ nal return, is the health care center:

No longer licensed in Connecticut; out of business



 

Merged/reorganized

 ______________________________________________________



Enter survivor’s CT Tax Registration No.



E. The health care center is currently in:



Receivership



Rehabilitation

Name of company

Connecticut Tax Registration Number

Taxpayer



Address

Number and street

PO Box

Date received (DRS use only)

Please



type

(FEIN)

City or town

State

ZIP code

Federal Employer ID Number

or print.



1. Total net direct subscriber charges less returned charges, including cancellations: See instructions. ....................

Subscriber charges received from:



2. The State of Connecticut to provide health care coverage for state employees, retirees, or their dependents ....

3. The State of Connecticut to provide health care coverage for retired teachers, their spouses, or their



surviving spouses covered by plans offered by the State Teachers’ Retirement System ................................



4. Connecticut municipalities to provide health coverage for their employees and dependents............................

5. Nonproﬁ t organizations or community action agencies to provide health coverage for their employees



and dependents .................................................................................................................................................



6. The federal government to provide coverage for Medicare patients ..................................................................



7. The State of Connecticut to provide health care coverage for Medicaid recipients ...........................................

8. The State of Connecticut to provide health care coverage for eligible beneﬁ ciaries under the HUSKY



Plan, Part A; HUSKY Plan, Part B; or the HUSKY Plus programs ....................................................................



9. The federal Employees Health Beneﬁ ts Fund to provide coverage for qualiﬁ ed enrollees................................

10. Individuals eligible for a health coverage tax credit and individuals eligible for a retirement beneﬁ t from



the Connecticut municipal employees’ retirement system and their dependents ..............................................



11. Total deductions: Add Lines 2 through 10. ........................................................................................................



12. Subtract Line 11 from Line 1.....................................................................................................................................



13. Tax: Multiply Line 12 by 1.75% (.0175). ....................................................................................................................



14. Enter amount from form CT-207K, Part 4, Line 36, Column C. ................................................................................



15. Net tax: Subtract Line 14 from Line 13. If less than zero, enter zero “0.” .................................................................



16. Enter prior year overpayment(s). ..............................................................................................................................



17. Payments made with estimated tax payment coupons Form 207 HCC ESA, ESB, ESC, and ESD. ......................



18. Payments made with extension request Form 207/207 HCC EXT. ........................................................................



19. Total prior payments: Add Lines 16, 17, and 18. ......................................................................................................



20. If Line 19 is greater than Line 15, enter amount overpaid. .......................................................................................



21. Amount to be: credited to 2015 estimated tax

(21a) $________________ refunded

(21b) $______________

For faster refund, use Direct Deposit by completing Lines 21c, 21d, and 21e.





21c. Checking

Savings

21d. Routing number





21e. Account number

21f. Will this refund go to a bank account outside the U.S.?

Yes



22. If Line 15 is greater than Line 19, enter amount owed.



23. If late: penalty

(23a) $________________ plus interest

(23b) $________________ See instructions. ...............



24. Interest on underpayment of estimated tax: Attach Form 207I. See instructions. ..................................................



25. Balance due with this return. Make check payable to Commissioner of Revenue Services. ..............................

Visit the Department of Revenue Services (DRS) website at to pay electronically.

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, 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

Sign Here

Print name of principal ofﬁ cer

Telephone number

(

)

Keep a copy

Email address of principal ofﬁ cer

of this return