Form 207 Hcc - Health Care Center Tax Return - Connecticut Department Of Revenue Services - 2011
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12011
Department of Revenue Services
Form 207 HCC
State of Connecticut
PO Box 2990
Health Care Center Tax Return
Hartford CT 06104-2990
Complete this return in blue or black ink only.
(Rev. 01/12)
General Information
A.
Check if this is an amended return.
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, is the insurance company:
No longer licensed in Connecticut; out of business
Merged/reorganized
______________________________________________________
Enter survivor’s CT Tax Registration No.
E. The insurance company 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
or print.
City or town
State
ZIP code
Federal Employer ID Number (FEIN)
1. Total net direct subscriber charges less returned charges, including cancellations: See instructions. ....................
1
00
Subscriber charges received from:
2. The State of Connecticut to provide health care coverage for state employees, retirees, or their dependents ....
2
00
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 ................................
3
00
4. Connecticut municipalities to provide health coverage for their employees and dependents............................
4
00
5. Nonprofit organizations or community action agencies to provide health coverage for their employees
and dependents .................................................................................................................................................
5
00
6. The federal government to provide coverage for Medicare patients. . ................................................................. .
.
6.
00
7. The State of Connecticut to provide health care coverage for Medicaid recipients ...........................................
7
00
8. The 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 ....................................................................
8
00
9. The federal Employees Health Benefits Fund to provide coverage for qualified enrollees................................
9
00
10. Individuals eligible for a health coverage tax credit and individuals eligible for a retirement benefit from
the Connecticut municipal employees’ retirement system and their dependents ..............................................
10
00
11. Total deductions: Add Lines 2 through 10. ........................................................................................................
11
00
12. Subtract Line 11 from Line 1.....................................................................................................................................
12
00
13. Health care center tax: Multiply Line 12 by 1.75% (.0175). ......................................................................................
13
00
14. Enter amount from form CT-207K, Part 4, Line 31, Column C. ................................................................................
14
00
15. Net tax: Subtract Line 14 from Line 13. If less than zero, enter zero “0.” .................................................................
15
00
16. Enter prior year overpayment(s). ..............................................................................................................................
16
00
17. Payments made with estimated tax payment coupons Form 207 HCC ESA, ESB, ESC, and ESD. ......................
17
00
18. Payments made with extension request Form 207/207 HCC EXT. ........................................................................
18
00
19. Total prior payments: Add Lines 16, 17, and 18. ......................................................................................................
19
00
20. If Line 19 is greater than Line 15, enter amount overpaid. .......................................................................................
20
00
21. Amount to be: credited to 2012 estimated tax
(21a) $________________ refunded
(21b) $______________
21
00
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.
22
00
23. If late: penalty
(23a) $________________ plus interest
(23b) $________________ See instructions. ...............
23
00
24. Interest on underpayment of estimated tax: Attach Form 207I. See instructions. ..................................................
24
00
25. Balance due with this return. Make check payable to Commissioner of Revenue Services. ..............................
25
00
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 fine of not
more than $5,000, 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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