Schedule Ct-Si Draft - Nonresident Or Part-Year Resident Schedule Of Income From Connecticut Sources - 2014

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2014
Department of Revenue Services
Schedule CT-SI
State of Connecticut
Nonresident or Part-Year Resident
(Rev. 12/14)
Schedule of Income From Connecticut Sources
Complete this schedule if you were a nonresident or part-year resident of Connecticut and attach it to Form CT-1040NR/PY.
Your fi rst name and middle initial
Last name
Your Social Security Number
•
•
__ __ __ __ __ __ __ __ __
•
•
•
•
•
•
If joint return, spouse’s fi rst name and middle initial
Last name
Spouse’s Social Security Number
• •
• •
__ __ __ __ __ __ __ __ __
•
•
•
•
See instructions on Page 28 before completing this schedule. Complete in blue or black ink only.
Part 1 - Connecticut Income - Part-Year Residents: Complete Schedule CT-1040AW, Part-Year Resident Income Allocation.
Add Columns B and D for each line of Schedule CT-1040AW and enter the totals on Lines 1 through 30 below.
Nonresidents: Enter the income received from Connecticut sources.
1. Wages, salaries, tips, etc. ..........................................................................................................................
1
2. Taxable interest .........................................................................................................................................
2
3. Ordinary dividends .....................................................................................................................................
3
4. Alimony received ........................................................................................................................................
4
5. Business income or (loss) ..........................................................................................................................
5
6. Capital gain or (loss) ..................................................................................................................................
6
7. Other gains or (losses) ...............................................................................................................................
7
8. Taxable amount of IRA distributions ...........................................................................................................
8
9. Taxable amount of pensions and annuities ................................................................................................
9
10. Rental real estate, royalties, partnerships, S corporations, trusts, etc. ......................................................
10
11. Farm income or (loss) ................................................................................................................................
11
12. Unemployment compensation ....................................................................................................................
12
13. Taxable amount of social security benefi ts .................................................................................................
13
14. Other income: See instructions. ................................................................................................................
14
00
15. Gross income from Connecticut sources: Add Lines 1 through 14. ...........................................................
15
Part 2 - Adjustments to Connecticut Income - Enter adjustments directly related to income reported above.
16. Reserved for future use ..............................................................................................................................
16
17. Certain business expenses of reservists, performing artists, and fee-basis government offi cials .............
17
18. Health savings account deduction ..............................................................................................................
18
19. Moving expenses .......................................................................................................................................
19
20. Deductible part of self-employment tax ......................................................................................................
20
21. Self-employed SEP, SIMPLE, and qualifi ed plans .....................................................................................
21
22. Self-employed health insurance deduction ................................................................................................
22
23. Penalty on early withdrawal of savings ......................................................................................................
23
24. Alimony paid. Recipient’s last name
____________________ SSN
_______– ____ – _______
24
25 IRA deduction .............................................................................................................................................
25
26. Student loan interest deduction ..................................................................................................................
26
27. Reserved for future use ..............................................................................................................................
27
28. Reserved for future use ..............................................................................................................................
28
29. Total adjustments: Add Lines 16 through 28. ............................................................................................
29
30. Income from Connecticut sources: Subtract Line 29 from Line 15.
00
Enter the amount here and on Form CT-1040NR/PY, Line 6. ..................................................................
30
Employee Apportionment Worksheet - Complete Lines A through G only when the income from employment is earned both inside
and outside Connecticut and the exact amount of Connecticut income is not known. Do not complete Lines A through G if you know
the exact amount of your Connecticut-sourced income. See instructions, Page 31.
A. Working days (or other basis) outside Connecticut .......................................................................................
A
B. Working days (or other basis) inside Connecticut .........................................................................................
B
C. Total working days: Add Line A and Line B. ..................................................................................................
C
D. Nonworking days (Holidays, weekends, etc.) ................................................................................................
D
.
E. Connecticut ratio: Divide Line B by Line C. Round to four decimal places. ................................................
E
F.
Total income being apportioned ....................................................................................................................
F
G. Connecticut income: Multiply Line E by Line F. Enter here and on Schedule CT-SI, Line 1. ......................
G
Basis, if other than working days: _______________________
P:\Special\AFP\PROD\FORMS\14\Schedule\Schedule CT-SI\CT-SI 20140911.indd
20140911
11:30 AM

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