Form Ct-941 - Connecticut Quarterly Reconciliation Of Withholding - 2015
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1Department of Revenue Services
2015
Form CT-941
PO Box 2931
Connecticut Quarterly Reconciliation of Withholding
Hartford CT 06104-2931
CT-941 (Rev. 12/14)
Complete this return in blue or black ink only.
General Instructions
Form CT-941 must be paid and fi led electronically. Do not send this paper return to the Department of Revenue Services (DRS),
unless you have been granted a waiver from DRS. See Electronic Filing Waiver, on Page 3.
Form CT-941 is used to reconcile quarterly Connecticut income tax withholding from wages only. Payers of nonpayroll amounts
must use Form CT-945, Connecticut Annual Reconciliation of Withholding for Nonpayroll Amounts.
Do not use this form to amend a previously fi led Form CT-941. See Amended Returns, on Page 4.
Name
Connecticut Tax Registration Number
This return MUST be fi led electronically!
Taxpayer
Number and street
PO Box
Federal Employer ID Number (FEIN)
Please
DO NOT MAIL paper return to DRS.
type
City or town
State
ZIP code
or print.
Enter reporting quarter (1, 2, 3, or 4)
Check here
if you no longer have employees in Connecticut
Due date
and enter date of last payroll:
/
/
M M
D D
Y Y Y Y
Section 1
1. Gross wages ..........................................................................................................................
1
00
2. Gross Connecticut wages ......................................................................................................
2
00
3. Connecticut tax withheld ....................................................................................................
3
00
4. Credit from prior quarter .......................................................................................................
4
00
5. Payments made for this quarter.............................................................................................
5
00
6. Total payments: Add Line 4 and Line 5. ................................................................................
6
00
7. Net tax due (or credit): Subtract Line 6 from Line 3. .............................................................
7
00
8a. Penalty: .........................................................................
8a
00
8b. Interest: .........................................................................
8b
00
8 Total penalty and interest: Add Line 8a and Line 8b. ...............................................................
8
00
9. Amount to be credited ...........................................................................................................
9
00
10. Amount to be refunded .........................................................................................................
10
00
For faster refund, use Direct Deposit by completing Lines 10a, 10b, and 10c.
10a. Checking
Savings
10b. Routing number
10c. Account number
10d. Will this refund go to a bank account outside the U.S.?
Yes
11
11. Total amount due: Add Line 7 and Line 8. ..........................................................................
00
Section 2 - Summary of Connecticut Tax Liability for the Calendar Quarter: See Instructions on back.
A
B
C
Pay
First Month
Second Month
Third Month
Period
1.
2.
3.
4.
5.
6.
7. Totals
8. Total liability for the quarter: Add Line 7, Columns A, B, and C. Enter total.
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.
Signature
Date
This return MUST be fi led electronically!
Title
Telephone number
DO NOT MAIL paper return to DRS.
(
)
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