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Department of Revenue Services

Form CT-990T EXT

2016

State of Connecticut

Application for Extension of Time to File

PO Box 5014

(Rev. 12/16)

Hartford CT 06102-5014

Unrelated Business Income Tax Return

990TEXT 1216W 01 9999

See instructions. Complete this form in blue or black ink only. Type or print.

For DRS



2016



Enter Income Year Beginning

and Ending

Use Only

M M - D D - Y Y Y Y

Organization name

Connecticut Tax Registration Number



Number and street

PO Box

Federal Employer ID Number (FEIN)



City, town, or post ofﬁ ce

State

ZIP code

Request for six-month extension of time to ﬁ le Form CT-990T only

Enter above the beginning and ending dates of the organization’s income year, Connecticut Tax Registration Number, and FEIN.

Check type of organization:

Corporation

Domestic trust

Foreign trust

Other

An application for an extension to ﬁ le Form CT-990T, with payment of tax tentatively believed to be due, must be submitted whether or

not an application for federal extension has been approved.

I request a six month extension of time to to ﬁ le my Form CT-990T, Connecticut Unrelated Business Income Tax Return, for calendar

year 2016, or until

(MMDDYYYY) for ﬁ scal year ending

(MMDDYYYY).

A federal extension will be requested on federal Form 8868, Application for Extension of Time to File an Exempt Organization Return, for

calendar year 2016 or ﬁ scal year beginning

(MMDDYYYY) and ending

(MMDDYYYY). If a

federal extension has not been ﬁ led, explain why you are requesting the Connecticut extension:

Notiﬁ cation will be sent only if extension request is denied

Computation of Tentative Return

1. Tentative amount of tax due for this income year, including surtax if applicable. See instructions. ... 1.

2. Reserved for future use ..................................................................................................................... 2.

3. Total amount of tax due for this income year: Enter amount from Line 1. .......................................... 3.

4a. Tax credits ...................................................................................... 4a.

4b. Payments of estimated tax ............................................................. 4b.

4c. Overpayment from prior year ......................................................... 4c.

4. Total tax credits and payments: Add Lines 4a, 4b, and 4c. ................................................................ 4.



5. Balance due with this return: Subtract Line 4 from Line 3. ................................................................ 5.

Declaration: I declare under the penalty of law that I have examined this return 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 the Department of Revenue Services (DRS) is a ﬁ ne of not more than $5,000, imprisonment

for not more than ﬁ ve 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.

Ofﬁ cer or ﬁ duciary’s name (print)

Ofﬁ cer or ﬁ duciary’s signature

Date

(MMDDYYYY)

Sign

Here

Title

Telephone number

Keep a

copy of

Paid preparer’s name (print)

Paid preparer’s signature