Schedule Ct-Si Draft - Nonresident Or Part-Year Resident Schedule Of Income From Connecticut Sources - 2012

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2012
Department of Revenue Services
Schedule CT-SI
State of Connecticut
Nonresident or Part-Year Resident
(Rev. 12/12)
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
DRAFT
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
9/24/2012
Part 2 - Adjustments to Connecticut Income - Enter adjustments directly related to income reported above.
16. Educator expenses .......................................................................................................................................... 16
17. Certain business expenses of reservists, 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
24. Alimony paid. Recipient’s last name
_______________________ SSN
25 IRA deduction .................................................................................................................................................. 25
26. Student loan interest deduction ....................................................................................................................... 26
27. Tuition and fees ............................................................................................................................................... 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
This refl ects the information on the federal 1040 as of the print date. Check the DRS website at for an updated Schedule CT-SI.
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 32.
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\12\SCHEDULE\Schedule CT-SI\CT-SI 20120731.indd20120731
10:55 AM

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