Form Ct-1041 - Connecticut Income Tax Return For Trusts And Estates Page 2

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1. Interest on state and local government obligations other than Connecticut

2. Exempt-interest dividends received from a mutual fund derived from state or municipal government

obligations other than Connecticut

3. Shareholder’s pro-rata share of S corporation nonseparately computed loss (Enter as a positive number)

4. Loss on sale of Connecticut state and local government bonds (Enter as a positive number)

5. Connecticut income tax deducted in determining federal taxable income prior to deductions

relating to distributions to beneficiaries

6. Other (Specify) _____________________________________________________

7. Total additions (Add Lines 1 through 6)

8. Interest on United States government obligations

9. Dividends from certain mutual funds derived from United States government obligations

10. Shareholder’s pro-rata share of S corporation nonseparately computed income

11. Gain on sale of Connecticut state and local government bonds

12. Refunds of Connecticut income tax

13. Other (Specify) ____________________________________________________

14. Total subtractions (Add Lines 8 through 13)

15. Connecticut fiduciary adjustment - (Subtract Line 14 from Line 7. This amount may be positive or

negative) Enter on Form CT-1041, Schedule B, Part 1, Column 5, Line f.

A. If the trust is an inter vivos trust, enter name, address and social security number of grantor: ____________________________________

B. If you check “part-year resident trust” on the front of this return, enter the date on which the trust became irrevocable: _____________

C. Does the estate or trust have an interest in real property or tangible personal property located in Connecticut?

YES

I declare under the penalties of false statement 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. Declaration of preparer (other than the taxpayer) is based on all information of which

preparer has any knowledge.

Signature of Fiduciary or Officer Representing Fiduciary

Date

Telephone Number

(

)

Paid Preparer’s Signature

Federal Employer ID Number

Keep a

copy of

this return

Firm Name and Address