Form Ct-1040x - Amended Connecticut Income Tax Return For Individuals

SCHEDULE 1 MODIFICATIONS TO FEDERAL ADJUSTED GROSS INCOME

(Enter all amounts as positive numbers)

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

32. Mutual fund exempt-interest dividends from non-Connecticut state or municipal government

Additions to

obligations other than Connecticut

Federal

33. Special depreciation allowance for qualified property placed in service prior to September 11, 2004

Adjusted

Gross Income

34. Taxable amount of lump-sum distributions from qualified plans not included in federal adjusted gross income

(See instructions,

35. Beneficiary’s share of Connecticut fiduciary adjustment (Enter only if greater than zero)

Page 3)

36. Loss on sale of Connecticut state and local government bonds

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

37. Allocated 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

38. Other - specify

39. TOTAL ADDITIONS (Add Lines 31 through 38); Enter here and on Line 2, Column C, on the front of this form.

40. Interest on U.S. government obligations

41. Exempt dividends from certain qualifying mutual funds derived from U.S. government obligations

Subtractions

From Federal

42. Social Security benefit adjustment (See Social Security Benefit Adjustment Worksheet, Page 4)

Adjusted

43. Refunds of state and local income taxes

Gross Income

44. Tier 1 and Tier 2 railroad retirement benefits and supplemental annuities

(See instructions,

45. Special depreciation allowance for qualified property placed in service during the preceding year

Page 3)

46. Beneficiary’s share of Connecticut fiduciary adjustment (Enter only if less than zero)

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

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

48. Allocated 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

49. Other - specify (Do not include out-of-state income)

50. TOTAL SUBTRACTIONS (Add Lines 40 through 49); Enter here and on Line 4, Column C, on the front of this form. 50

SCHEDULE 2 CREDIT FOR INCOME TAXES PAID TO QUALIFYING JURISDICTIONS

(See instructions for Form CT-1040 or Form CT-1040NR/PY)

MODIFIED CONNECTICUT ADJUSTED GROSS INCOME

51.

COLUMN A

COLUMN B

FOR EACH COLUMN, ENTER THE FOLLOWING:

Important:

Name

Code

Name

Code

You must

52. Enter qualifying jurisdiction’s name and two-letter code

attach a copy

53. Non-Connecticut income included on Line 51 and reported on a qualifying

of your return

jurisdiction’s income tax return (from Schedule 2 Worksheet)

filed with the

qualifying

54. Divide Line 53 by Line 51 (may not exceed 1.0000)

jurisdiction(s)

55. Income tax liability (Subtract Line 15, Column C, from Line 10, Column C) 55

or your credit

56. Multiply Line 54 by Line 55

will be

disallowed.

57. Income tax paid to a qualifying jurisdiction

58. Enter the lesser of Line 56 or Line 57

59. TOTAL CREDIT (Add Line 58, all columns)

Enter here and on Line 11, Column C, on the front of this form.

MAIL TO:

Department of Revenue Services

Make your check or money order payable to: “Commissioner of Revenue Services”

To ensure proper posting of your payment, write your Social Security Number(s) and

PO Box 2978

“2004 Form CT-1040X” on your check or money order.

Hartford CT 06104-2978

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 to DRS is a fine of not more than $5,000, or imprisonment for not more

than five 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

Spouse’s Signature (if joint return)

Date

Sign

Here

Paid Preparer’s Signature

Date

Telephone Number

Preparer’s SSN or PTIN

Keep a

(