Form Ct-1120si - Supplemental Attachment Page 2
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1
2Form CT-1120SI
Supplemental Attachment (Continued)
(Part IV, Part V, and Part VI)
PART IV Shareholder Information
Federal Employer
Nonresident
NAME AND ADDRESS OF SHAREHOLDER
Identification Number
% Stock
or Social Security Number
Ownership
Yes
No
Shareholder #
(List nonresidents first, residents next, and other shareholders last)
#
#
#
#
PART V
Shareholders’ Share of Connecticut Modifications
SHAREHOLDER
ADDITIONS
# _____
# _____
# _____
# _____
ENTER ALL AMOUNTS AS POSITIVE NUMBERS
1. Interest on state and local obligations other
than Connecticut .......................................................
2. Exempt-interest dividends on state and local
obligations other than Connecticut .........................
3. Certain deductions relating to income exempt
from Connecticut Income Tax .................................
4. Special depreciation allowance for
qualified property .....................................................
5. Other (Specify) .........................................................
SUBTRACTIONS
ENTER ALL AMOUNTS AS POSITIVE NUMBERS
6. Interest on United States obligations .....................
7. Exempt dividends from certain qualifying
mutual funds .............................................................
8. Certain expenses related to income exempt from
federal income tax but subject to Connecticut tax ....
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3
9. Reserved for future use ...........................................
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3
10. Other (Specify) .........................................................
PART VI
Computation of Connecticut Source Income of Nonresident Shareholders
SHAREHOLDER
Connecticut-sourced portion of items from
# _____
# _____
# _____
# _____
federal Schedule K-1 (Form 1120S)
1. Ordinary (nonseparately stated) income (loss) .......
2. Net income (loss) from rental real estate activities ..
3. Net income (loss) from other rental activities ...........
4. Portfolio income .........................................................
5. Expense deduction for property under I.R.C. §179 .
6. Other deductions .......................................................
7. Net gain (loss) under I.R.C. §1231
(other than due to casualty or theft) ........................
8. Other income (loss) (Attach schedule) ....................
Form CT-1120SI Supplemental Attachment Back (Rev. 12/02)
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