Free CT-33-C - New York

Staple forms here

CT-33-C
Amended return
Employer identification number

New York State Department of Taxation and Finance

Captive Insurance Company Franchise Tax Return
Tax Law ­ Article 33
All filers must enter tax period: beginning
File number Business telephone number

ending
If you claim an overpayment, mark an X in the box

(
Legal name of corporation

)
Trade name/DBA State or country of incorporation

Mailing name (if different from legal name above)

Date received (for Tax Department use only)

c/o
Number and street or PO box Date of incorporation

City

State

ZIP code

Foreign corporations: date began business in NYS

NAICS business code number (see instructions)

If address above is new, mark an X in the box

Principal business activity

If your name, employer identification number, address, Audit (for Tax Department use only) or owner/officer information has changed, you must file Form DTF-95. If only your address has changed, you may file Form DTF-96. You can get these forms from our Web site, by phone, or by fax. See Need help? in the instructions.

Federal return was filed on (mark an X in one): 1120-L

1120-PC

Consolidated

Other:
Payment enclosed

A. Pay amount shown on line 19. Make payable to: New York State Corporation Tax Attach your payment here. Detach all check stubs. (See instructions for details.)

A.

Computation of tax and installment payments of estimated tax
Tax on New York State gross direct premiums 1 First $20,000,000 of gross direct premiums................... × .004 = 2 $20,000,001-$40,000,000 of gross direct premiums ..... × .003 = 3 $40,000,001-$60,000,000 of gross direct premiums ..... × .002 = 4 Excess of $60,000,000 of gross direct premiums .......... × .00075 = Tax on New York State reinsurance premiums 5 First $20,000,000 of reinsurance premiums .................. × .00225 = 6 $20,000,001-$40,000,000 of reinsurance premiums ..... × .0015 = 7 $40,000,001-$60,000,000 of reinsurance premiums ..... × .0005 = 8 Excess of $60,000,000 of reinsurance premiums .......... × .00025 = Computation of tax and estimated tax due 9 Tax due based upon premiums (add lines 1 through 8) .................................................................... 10 Minimum tax...................................................................................................................................... 11 Tax due (enter the greater of line 9 or 10) ............................................................................................ First installment of estimated tax for next period: 12a If you filed a request for extension, enter amount from Form CT-5, line 2 ...................................... 12b If you did not file Form CT-5, see instructions ................................................................................ 13 Total (add line 11 and line 12a or 12b) ................................................................................................... 14 Total prepayments from line 27 ....................................................................................................... 15 Balance (if line 14 is less than line 13, subtract line 14 from line 13) ......................................................... 16 Estimated tax penalty (see instructions; mark an X in the box if Form CT-222 is attached) .............. 17 Interest on late payment (see instructions) ........................................................................................ 18 Late filing and late payment penalties (see instructions) ................................................................... 19 Balance due (add lines 15 through 18 and enter here; enter the payment amount on line A above) .......... 20 Overpayment (if line 13 is less than line 14, subtract line 13 from line 14) .............................................. 21 Amount of overpayment to be credited to next period .................................................................... 22 Refund of overpayment (subtract line 21 from line 20) ....................................................................... 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12a. 12b. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

5,000 00

Continued on page 2

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Page 2 of 2 CT-33-C (2008)

Composition of prepayments on line 14 (see instructions)
Date paid Amount

23 24a 24b 24c 25 26 27

Mandatory first installment .......................................................................................... 23. Second installment from Form CT-400........................................................................ 24a. Third installment from Form CT-400............................................................................ 24b. Fourth installment from Form CT-400 ......................................................................... 24c. Payment with extension request (from Form CT-5, line 5) .............................................. 25. Overpayment credited from prior years ............................................................................................ 26. Total prepayments (add lines 23 through 26; enter here and on line 14) ................................................... 27. No

Have you been audited by the Internal Revenue Service in the past 5 years? ............................................................ Yes (if Yes, list years)

Designee's name (print) Third ­ party Yes No designee Designee's e-mail address (see instructions)

Designee's phone number ( )

PIN
Official title Date ID number Address City State Date ZIP code

Certification: I certify that this return and any attachments are to the best of my knowledge and belief true, correct, and complete. Authorized person Paid preparer use only
Signature of authorized person E-mail address of authorized person

Firm's name (or yours if self-employed) Signature of individual preparing this return E-mail address of individual preparing this return

Attach a copy of your complete federal return and a copy of your New York Captive Insurance Company Annual Statement as filed with the New York State Insurance Department. See instructions for where to file.

43102080094