Department of Revenue Services
Form CT-941X
PO Box 2931
Hartford, CT 06104-2931
Amended Connecticut Reconciliation of Withholding
Complete this return in blue or black ink only. See instructions on back before completing.
(Rev. 12/12)
Name of employer
Connecticut Tax Registration Number
Address (number and street)
Federal Employer ID Number (FEIN)
City, town, or post offi ce
State
ZIP code
Name of form being amended (check one):
Form CT-941
Form CT-945
Form CT-941 HHE Household employer
Quarter being amended (Form CT-941 fi lers only, check one) and enter calendar year (all fi lers):
Calendar
year
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
_________________
January - March
A pril - June
July - September
October - December
Column A
Column B
Column C
.
Amount as Originally
Net Change
Corrected
Reported on
Amount
(Increase or Decrease)
CT-941 or CT-945
1. Enter gross wages from Form CT-941, Line 1, or
gross nonpayroll amounts from Form CT-945, Line 1. ..........1.
2. Enter gross CT wages from Form CT-941, Line 2, or gross
CT nonpayroll amounts from Form CT-945, Line 2. ...............2.
3. Enter CT tax withheld from Form CT-941 or
Form CT-945, Line 3. .............................................................3.
4. Enter credit from prior quarter, if any, of the same
calendar year (Form CT-941 fi lers only). .............................4.
5. Deposits made with Form CT-WH (Form CT-941) or
Form CT-8109 (Form CT-945) ................................................5.
6. Amount paid with Form CT-941, Form CT-945,
or Form CT-941 HHE .............................................................6.
7. Total payments: Add Lines 4, 5, and 6. ..................................7.
8. Overpayment, if any, as shown on original return (or as previously adjusted) .......................................... 8.
9. Subtract Line 8 from Line 7. ...................................................................................................................... 9.
10. Net tax due or (credit): Subtract Line 9 from Line 3. ............................................................................... 10.
11. Interest on net tax due ............................................................................................................................. 11.
12. Total amount due or (credit): Add Line 10 and Line 11. Credits cannot be transferred to
another account. ................................................................................................................................... 12.
Overpayment: If amount on Line 12 is a credit, enter the overpayment
Use the Taxpayer Service Center (TSC) to electronically
amount here
$ ________________
and check if:
fi le this return. See TSC on back.
Applied to next return or
Refunded
If fi ling by mail, make check payable to Commissioner of Revenue
Services. Write your CT Tax Registration Number on your check. Do
Declaration: I declare that (check the appropriate box)
not send cash. The Department of Revenue Services (DRS) may submit
All overwithheld Connecticut income taxes for the current calendar
your check to your bank electronically.
year were repaid to employees prior to the end of the current calendar
Attach a copy of all applicable schedules and forms.
year. (You must keep in your records each employee’s written receipt
Mail to:
Department of Revenue Services
showing the date and amount of repayment.)
PO Box 2931
None of this refund or credit was withheld from employees.
Hartford CT 06104-2931
I further 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 DRS is a fi ne of not
more than $5,000, imprisonment for not more than fi ve years, or both.
Signature of employer
Date
Sign Here
Keep a copy
Paid preparer’s signature
Date
FEIN
of this return
for your
Firm name and address
Telephone number
records.
(
)
Complete the explanation of changes section on reverse.