Form Ct-1127 - Application For Extension Of Time For Payment Of Income Tax - 2010
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Department of Revenue Services
2010
State of Connecticut
Form CT-1127
25 Sigourney St Ste 2
Hartford CT 06106-5032
Application for Extension of Time for Payment of Income Tax
(Rev. 12/10)
Place this form on top of your completed Connecticut income tax return. Complete in blue or black ink only.
This form is not an extension of time to fi le. See How to Get an Extension of Time to File (on back) for additional information.
You must fi le this form on or before the due date of your return or your extension request will be denied.
Any reference in this document to a spouse also refers to a party to a civil union recognized under Connecticut law.
Your fi rst name and middle initial
Last name
Your Social Security Number (SSN)
__ __ __
__ __ __ __ __ __
• •
• •
• •
• •
If a joint return, spouse’s fi rst name and middle initial
Last name
Spouse’s Social Security Number
Taxpayer
__ __ __
__ __ __ __ __ __
• •
• •
• •
• •
Please type
Name of estate, trust, partnership, or entity
Federal Employer Identifi cation Number
• •
or print.
__ __
__ __ __ __ __ __ __
• •
Mailing address (number and street), apartment number, PO box
Daytime telephone number
(
)
DRS use only
City, town, or post offi ce
State
ZIP code
–
– 20
I request a six-month extension of time to October 15, 2011, to pay my Connecticut income tax of $ ________________ for
the year beginning January 1, 2010, and ending December 31, 2010.
If you are not a calendar year taxpayer, complete the following statement:
I request a six-month extension of time to _________________ , to pay my Connecticut income tax of $ _______________
for the year beginning ____________________ and ending ________________________.
This extension is necessary and payment of the tax at this time will cause me undue hardship because: (If more space is needed,
attach a separate sheet.) _______________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
I am unable to borrow money to pay the tax because: ________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
As evidence of the need for the extension, I am attaching: (1) a statement of assets including all bank accounts, receivables,
notes, stocks, bonds, cash value life insurance, automobiles, and real estate and liabilities as of the last day of the preceding
month showing book and market values of assets and whether any securities are listed or unlisted; and (2) an itemized list of
receipts (income) and disbursements (expenses) for the three months before the date the tax is due.
You will be notifi ed only if your extension request is denied.
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 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.
Your signature
Date
Sign
Spouse’s signature
Date
Here
Paid preparer’s signature
Date
Telephone
Preparer’s SSN or PTIN
Keep a
(
)
copy
for your
Firm’s name, address, and ZIP code
FEIN
records.
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