Form Ct-941x - Amended Connecticut Reconciliation Of Withholding - 2000

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STATE OF CONNECTICUT
FORM CT-941X
DEPARTMENT OF REVENUE SERVICES
(Rev. 7/00)
AMENDED CONNECTICUT QUARTERLY RECONCILIATION OF WITHHOLDING
NAME OF EMPLOYER
CONNECTICUT TAX REGISTRATION NUMBER
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ADDRESS (Number and Street)
FEDERAL EMPLOYER ID NUMBER
City, Town or Post Office
State
ZIP Code
Calendar
Check only one box to indicate the quarter and enter the taxable year below:
Year
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<
<
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1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
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H
H
H
H
January - March
April - June
July - September
October - December
AMOUNT AS ORIGINALLY
NET CHANGE
CORRECTED
REPORTED ON CT-941
Increase or (Decrease)
AMOUNT
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1. Gross wages and nonpayroll amounts ............................. 1
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2. Gross Connecticut wages and nonpayroll amounts ..... 2
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3. Connecticut tax withheld ...................................................... 3
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4. Credits from prior period ...................................................... 4
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5. Payments made with Form CT-WH for this quarter ....... 5
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6. Amount remitted with Form CT-941 ................................... 6
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7. Total deposits (Add Lines 4, 5, and 6) .............................. 7
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8. Overpayment, if any, as shown on original return (or as previously adjusted) ...................................... 8
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9. Subtract Line 8 from Line 7 ............................................................................................................................... 9
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10. Net tax due or (credit) (Subtract Line 9 from Line 3) ................................................................................. 1 0
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11. Interest ................................................................................................................................................................. 11
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12. TOTAL AMOUNT DUE OR (CREDIT) (Add Line 10 and Line 11) ............................................................ 1 2
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Overpayment:
$ ____________________ a n d
If amount on Line 12 is a credit, enter overpayment amount here
<
<
H
H
check if to be:
Applied to next quarter OR
Refunded
H
H
Was any of this overpayment withheld from employee wages?
YES
NO
Mail to:
Underpayment:
Pay total amount shown on Line 12.
Department of Revenue Services
Make check payable to: COMMISSIONER OF REVENUE SERVICES
PO Box 2931
Hartford CT 06104-2931
Write your Connecticut Tax Registration Number on your check.
Attach a copy of all applicable schedules and forms (see instructions).
Declaration:
I declare under the penalty of false statement that I have examined this return and, to the best of my knowledge and belief, it is true, complete, and
correct. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two thousand dollars, or both.)
Signature of Employer
Date
Sign Here
Paid Preparer’s Signature
Date
Federal Employer ID Number
<
Keep a copy
of this return
Firm Name and Address
for your
records
Complete explanation of changes section on reverse

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