Form 207hcc - Health Care Center Tax Return - 2001 printable pdf download

Department of Revenue Services

State of Connecticut

Form 207HCC

2001

PO Box 2990

Hartford CT 06104-2990

Health Care Center Tax Return

(Rev. 12/01)

Purpose - Each health care center authorized to do health care business in Connecticut must file this return on or before March 1, 2002, to

report its health care center tax liability for calendar year 2001.

A copy of Schedule T and the Statement of Revenue, Expenses, and Net Worth from the Annual Statement filed with the

Insurance Department must accompany this return.

CT Health Care Center Tax Registration Number

Date Received (For Department Use Only)

Federal Employer Identification Number

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

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 municipal employees

5 Nonprofit organizations to provide health coverage for employees and their dependents

6 The federal government to provide coverage for Medicare patients

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

State of Connecticut to provide health care coverage for eligible beneficiaries under the HUSKY Plan, Part A;

HUSKY Plan, Part B; or the HUSKY Plus Programs

The State of Connecticut to provide health care coverage for recipients of state administered general

assistance

10 The federal Employees Health Benefits Fund to provide coverage for qualified enrollees

11 Total Deductions (Add Lines 2 through 10)

12 Subtract Line 11 from Line 1

13 Health care center tax: Multiply Line 12 by 1.75% (.0175)

14 HUSKY credit (See instructions on reverse side)

15 Other Connecticut business tax credits (See instructions on reverse side)

16 Total Credits (Add Line 14 and Line 15)

17 Subtract Line 16 from Line 13. (If less than zero, enter zero)

18 Overpayment applied from prior year

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

20 Payments made with extension request (Form 207HCC EXT)

21 Total payments (Add Lines 18, 19, and 20)

22 If Line 21 is greater than Line 17, enter amount overpaid

23 Amount to be credited to 2002 estimated tax (23a) $_________________ Refunded (23b)__________________ 23

24 If Line 17 is greater than Line 21, enter amount owed

25 If Late: penalty (23a) $____________________ plus interest (23b) $____________________ (See instructions) 25

26 Interest on underpayment of estimated tax (Attach Form 207 I) (See instructions)

27 Balance due with this return (Make check payable to: Commissioner of Revenue Services)

Declaration: I declare under the penalties 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 that 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