Form Ct-1040ez - Connecticut Resident Ez Income Tax Return

Form CT-1040EZ - Page 2

Your Social

Security Number

9. Enter amount from Line 8.

Column A

Column B

Column C

Employer’s federal ID No. from Box b of W-2,

Connecticut Wages, Tips, etc.

or Payer’s federal ID No. from W-2G, or 1099

Connecticut Income Tax Withheld

–

10a.

W-2, W-2G,

and 1099

–

10b.

Federal

Identification

–

10c.

Information

(Only enter

–

10d.

information from

10d.

your W-2, W-2G,

–

and 1099 forms

10e.

if Connecticut

–

income tax was

10f.

withheld.)

–

10g.

10h.

Enter amount from Supplemental Schedule CT-1040WH, Line 3.

10h.

10. Total Connecticut Income Tax Withheld (Add amounts in Column C and enter here.)

10.

You must complete Columns A, B, and C or your withholding will be disallowed.

11. All 2005 estimated tax payments and any overpayments applied from a prior year

11.

12. Payments made with Form CT-1040 EXT (Request for extension of time to file)

12.

13. Total Payments (Add Lines 10, 11, and 12.)

13.

14. Overpayment (If Line 13 is more than Line 9, subtract Line 9 from Line 13.)

14.

15. Amount of Line 14 you want applied to your 2006 estimated tax

15.

16. Total Contributions of Refund to Designated Charities (From Schedule 3EZ, Line 29) 16.

17. Refund (Subtract Lines 15 and 16 from Line 14.)

For faster refund, use Direct Deposit by completing Lines 17a, 17b, and 17c.

17.

17a.Type:

17b. Routing

17c. Account

checking

Number

savings

18. Total Amount Due (If Line 9 is more than Line 13, subtract Line 13 from Line 9.)

18.

Declaration: 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 or document 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

Daytime Telephone Number

(

)

Spouse’s Signature (if joint return)

Date

Daytime Telephone Number

(

)

Paid Preparer’s Signature

Date

Telephone Number

Preparer’s SSN or PTIN

(

)

Firm’s Name, Address, and ZIP Code

FEIN

Third Party Designee - Complete the following if you wish to authorize DRS to contact another person about this return.

Designee’s Name

Telephone Number

Personal Identification Number (PIN)

Complete applicable schedules on Form CT-1040EZ - Page 3.

Form Ct-1040ez - Connecticut Resident Ez Income Tax Return - 2005 Page 2

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