Fillable Form 115A , Premium Tax Return Tax on Premiums Paid to ... - ct

Description
STATE OF CONNECTICUT DEPARTMENT OF REVENUE SERVICES PO BOX 2990 HARTFORD CT 06104-2990 FORM 115A PREMIUM TAX RETURN TAX ON PREMIUMS PAID TO UNAUTHORIZED INSURERS For Calendar Year FORM 115A (Rev. 12/99) 19 Connecticut Tax Registration Number Federal Employer Identification Number Date Received (For Department Use Only) Please change Name and/or Address if shown incorrectly at right SCHEDULE OF INSURANCE PURCHASED...
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