Fill and Sign the Finance Invoice Editing Template Form

207F ESA - First Installment Estimated Insurance Premiums Tax Payment Coupon Foreign and Nonresident Insurance Companies (Rev. 5/05) CT Insurance Premiums Tax Reg. No. X Date Received (DRS USE ONLY) X Federal Employer ID Number X 1 Enter 30% (.30) of the tax shown on 2004 Form 207F, Line 15 1 2 Enter amount from Schedule 1, Line 5 (on back) 2 3 Enter the lesser of Line 1 or Line 2 3 4 Enter overpayment from prior year applied to estimated tax for current year 4 5 Payment due with this coupon (Subtract Line 4 from Line 3) X 5 Please change name or mailing address, or both, if shown incorrectly at right Due Date: Estimated Insurance Premiums Tax Payment Coupon Foreign and Nonresident Insurance Companies (Rev. 5/05) CT Insurance Premiums Tax Reg. No. Date Received (DRS USE ONLY) X Federal Employer ID Number Enter 60% (.60) of the tax shown on 2004 Form 207F, Line 15 1 2 Enter amount from Schedule 1, Line 5 (on back) 2 3 Enter the lesser of Line 1 or Line 2 3 4 Enter amount paid with Form 207F ESA plus overpayment from prior year applied to estimated tax for current year 4 5 Payment due with this coupon (Subtract Line 4 from Line 3) Please change name or mailing address, or both, if shown incorrectly at right X Federal Employer ID Number Department of Revenue Services State of Connecticut PO Box 2990 Hartford CT 06104-2990 1 2 Enter amount from Schedule 1, Line 5 (on back) 2 3 Enter the lesser of Line 1 or Line 2 3 4 Enter amount paid with Forms 207F ESA and 207F ESB plus overpayment from prior year applied to estimated tax for current year 4 Payment due with this coupon (Subtract Line 4 from Line 3) Please change name or mailing address, or both, if shown incorrectly at right Federal Employer ID Number Department of Revenue Services State of Connecticut PO Box 2990 Hartford CT 06104-2990 Organized Under Laws of For Calendar Year Ending 1 Enter the tax shown on 2004 Form 207F, Line 15 1 2 Enter amount from Schedule 1, Line 5 (on back) 2 3 Enter the lesser of Line 1 or Line 2 3 4 Enter amount paid with Forms 207F ESA, 207F ESB, and 207F ESC plus overpayment from prior year applied to estimated tax for current year 4 X 5 Please change name or mailing address, or both, if shown incorrectly at right September 15 Make Checks Payable To: Commissioner of Revenue Services Mail To: Department of Revenue Services Processing Section PO Box 2990 Hartford CT 06104-2990 (Rev. 5/05) X X 5 Due Date: 207F ESD - Fourth Installment Estimated Insurance Premiums Tax Payment Coupon Foreign and Nonresident Insurance Companies Date Received (DRS USE ONLY) Organized Under Laws of ________________ For Calendar Year Ending Enter 80% (.80) of the tax shown on 2004 Form 207F, Line 15 5 CT Insurance Premiums Tax Reg. No. June 15 1 X X 5 Make Checks Payable To: Commissioner of Revenue Services Mail To: Department of Revenue Services Processing Section PO Box 2990 Hartford CT 06104-2990 (Rev. 5/05) Date Received (DRS USE ONLY) X Due Date: 207F ESC - Third Installment Estimated Insurance Premiums Tax Payment Coupon Foreign and Nonresident Insurance Companies X ________________ Organized Under Laws of For Calendar Year Ending Department of Revenue Services State of Connecticut PO Box 2990 Hartford CT 06104-2990 1 X CT Insurance Premiums Tax Reg. No. March 15 Make Checks Payable To: Commissioner of Revenue Services Mail To: Department of Revenue Services Processing Section PO Box 2990 Hartford CT 06104-2990 207F ESB - Second Installment X Organized Under Laws of ________________ For Calendar Year Ending Department of Revenue Services State of Connecticut PO Box 2990 Hartford CT 06104-2990 _____________ X 5 Payment due with this coupon (Subtract Line 4 from Line 3) Due Date: December 15 Make Checks Payable To: Commissioner of Revenue Services Mail To: Department of Revenue Services Processing Section PO Box 2990 Hartford CT 06104-2990 Who Must File This Coupon Each foreign or nonresident insurance company carrying on an insurance business in Connecticut whose insurance premiums tax, after the application of guaranty association assessment credits, Insurance Department assessment credit (if applicable), and general business tax credits (as defined in Special Notice 2003(17), 2003 Legislation Affecting the Insurance Premiums Tax), for calendar year 2005 will be $1,000 or more must file this coupon. Required Annual Payment For estimated insurance premiums tax purposes, a foreign or nonresident insurance company’s required annual payment is the lesser of: • 90% (.90) of the tax that will be shown on its 2005 Form 207F (after the application of guaranty association assessment credits, the Insurance Department assessment credit (if applicable), and general business tax credits); or • 100% of the tax shown on your 2004 Form 207F, Line 15. Interest If the payment due with this coupon is not made on or before the due date of this coupon, interest will accrue at the rate of 1% (.01) per month, or fraction of a month, on the amount not paid from the due date of this coupon until the date of payment. Schedule 1 1 Enter estimated insurance premiums tax due for calendar year 2005 prior to the application of guaranty association assessment credits, Insurance Department assessment credit (if applicable), and general business tax credits. 00 2 Multiply Line 1 by 70% (.70) 00 3 Enter estimated Insurance Department assessment credit (if applicable), and general business tax credits against insurance premiums tax due for calendar year 2005. (May not exceed amount entered on Line 2) 00 4 Subtract Line 3 from Line 1 00 5 Multiply Line 4 by 27% (.27) 00 207F ESA Back (Rev. 5/05) Who Must File This Coupon Each foreign or nonresident insurance company carrying on an insurance business in Connecticut whose insurance premiums tax, after the application of guaranty association assessment credits, Insurance Department assessment credit (if applicable), and general business tax credits (as defined in Special Notice 2003(17), 2003 Legislation Affecting the Insurance Premiums Tax), for calendar year 2005 will be $1,000 or more must file this coupon. Required Annual Payment For estimated insurance premiums tax purposes, a foreign or nonresident insurance company’s required annual payment is the lesser of: • 90% (.90) of the tax that will be shown on its 2005 Form 207F (after the application of guaranty association assessment credits, the Insurance Department assessment credit (if applicable), and general business tax credits); or • 100% of the tax shown on your 2004 Form 207F, Line 15. Interest If the payment due with this coupon is not made on or before the due date of this coupon, interest will accrue at the rate of 1% (.01) per month, or fraction of a month, on the amount not paid from the due date of this coupon until the date of payment. Schedule 1 1 Enter estimated insurance premiums tax due for calendar year 2005 prior to the application of guaranty association assessment credits, Insurance Department assessment credit (if applicable), and general business tax credits. 00 2 Multiply Line 1 by 70% (.70) 00 3 Enter estimated Insurance Department assessment credit (if applicable), and general business tax credits against insurance premiums tax due for calendar year 2005. (May not exceed amount entered on Line 2) 00 4 Subtract Line 3 from Line 1 00 5 Multiply Line 4 by 54% (.54) 00 207F ESB Back (Rev. 5/05) Who Must File This Coupon Each foreign or nonresident insurance company carrying on an insurance business in Connecticut whose insurance premiums tax, after the application of guaranty association assessment credits, Insurance Department assessment credit (if applicable), and general business tax credits (as defined in Special Notice 2003(17), 2003 Legislation Affecting the Insurance Premiums Tax), for calendar year 2005 will be $1,000 or more must file this coupon. Required Annual Payment For estimated insurance premiums tax purposes, a foreign or nonresident insurance company’s required annual payment is the lesser of: • 90% (.90) of the tax that will be shown on its 2005 Form 207F (after the application of guaranty association assessment credits, the Insurance Department assessment credit (if applicable), and general business tax credits); or • 100% of the tax shown on your 2004 Form 207F, Line 15. Interest If the payment due with this coupon is not made on or before the due date of this coupon, interest will accrue at the rate of 1% (.01) per month, or fraction of a month, on the amount not paid from the due date of this coupon until the date of payment. Schedule 1 1 Enter estimated insurance premiums tax due for calendar year 2005 prior to the application of guaranty association assessment credits, Insurance Department assessment credit (if applicable), and general business tax credits. 00 2 Multiply Line 1 by 70% (.70) 00 3 Enter estimated Insurance Department assessment credit (if applicable), and general business tax credits against insurance premiums tax due for calendar year 2005. (May not exceed amount entered on Line 2) 00 4 Subtract Line 3 from Line 1 00 5 Multiply Line 4 by 72% (.72) 00 207F ESC Back (Rev. 5/05) Who Must File This Coupon Each foreign or nonresident insurance company carrying on an insurance business in Connecticut whose insurance premiums tax, after the application of guaranty association assessment credits, Insurance Department assessment credit (if applicable), and general business tax credits (as defined in Special Notice 2003(17), 2003 Legislation Affecting the Insurance Premiums Tax), for calendar year 2005 will be $1,000 or more must file this coupon. Required Annual Payment For estimated insurance premiums tax purposes, a foreign or nonresident insurance company’s required annual payment is the lesser of: • 90% (.90) of the tax that will be shown on its 2005 Form 207F (after the application of guaranty association assessment credits, the Insurance Department assessment credit (if applicable), and general business tax credits); or • 100% of the tax shown on your 2004 Form 207F, Line 15. Interest If the payment due with this coupon is not made on or before the due date of this coupon, interest will accrue at the rate of 1% (.01) per month, or fraction of a month, on the amount not paid from the due date of this coupon until the date of payment. Schedule 1 1 Enter estimated insurance premiums tax due for calendar year 2005 prior to the application of guaranty association assessment credits, Insurance Department assessment credit (if applicable), and general business tax credits. 00 2 Multiply Line 1 by 70% (.70) 00 3 Enter estimated Insurance Department assessment credit (if applicable), and general business tax credits against insurance premiums tax due for calendar year 2005. (May not exceed amount entered on Line 2) 00 4 Subtract Line 3 from Line 1 00 5 Multiply Line 4 by 90% (.90) 00 207F ESD Back (Rev. 5/05)