Form Ct-1040 - Connecticut Resident Income Tax Return - 2012 Page 2
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1
2
3
4-
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Your Social Security Number
2012 Form CT-1040 - Page 2 of 4
00
.
17. Enter amount from Line 16.
17.
,
,
3
Column B
Column C
Column A
Connecticut income tax withheld
Employer’s federal ID No. from Box b of W-2,
Connecticut wages, tips, etc.
or payer’s federal ID No. from Form 1099
.
–
00
.
00
18a.
18a.
,
,
W-2 and 1099
.
–
Information
00
.
18b.
18b.
,
,
00
Only enter
.
–
information
00
18c.
18c.
.
00
,
,
from your W-2
.
–
and 1099 forms
00
18d.
18d.
.
00
,
,
if Connecticut
.
–
.
income tax
00
18e.
18e.
00
,
,
was withheld.
.
–
00
.
18f.
18f.
00
,
,
.
–
00
18g.
18g.
.
00
,
,
.
00
,
,
18h. Additional CT withholding from Supplemental Schedule CT-1040WH 18h.
18. Total Connecticut income tax withheld: Add amounts in Column C and enter here.
.
00
,
,
You must complete Columns A, B, and C or your withholding will be disallowed. 18.
.
00
,
,
19. All 2012 estimated tax payments and any overpayments applied from a prior year 19.
.
00
,
,
20. Payments made with Form CT-1040 EXT (Request for extension of time to fi le)
20.
00
.
20a. Connecticut earned income tax credit: From Schedule CT-EITC, Line 16.
20a.
,
.
,
,
00
21. Total payments: Add Lines 18, 19, 20, and 20a.
21.
4
.
,
,
00
22. Overpayment: If Line 21 is more than Line 17, subtract Line 17 from Line 21.
22.
.
00
23. Amount of Line 22 overpayment you want applied to your 2013 estimated tax
23.
,
,
.
24. Total contributions of refund to designated charities from Schedule 5, Line 70
24.
,
,
00
25. Refund: Subtract Lines 23 and 24 from Line 22. For faster refund, use direct
deposit by completing Lines 25a, 25b, and 25c. If you do not elect direct deposit,
.
,
,
00
in most cases, the refund will be issued by debit card.
25.
25a. Checking
25b. Routing
25c. Account
Savings
number
number
25d. Will this refund go to a bank account outside the U.S.?
Yes
5
.
00
26. Tax due: If Line 17 is more than Line 21, subtract Line 21 from Line 17.
26.
,
,
.
27. If late: Enter penalty. Multiply Line 26 by 10% (.10).
27.
00
,
,
28. If late: Enter interest. Multiply Line 26 by number of months or fraction of a month
.
00
,
,
late, then by 1% (.01).
28.
.
,
,
00
29. Interest on underpayment of estimated tax from Form CT-2210:
29.
See instructions, Page 21.
.
00
,
,
30.
30. Total amount due: Add Lines 26 through 29.
6
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 fi ne of not more than $5,000, or imprisonment for not more than fi ve 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
(
)
Your email address
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 to authorize DRS to contact another person about this return.
(PIN)
Designee’s name
Telephone number
Personal identifi cation number
Complete applicable schedules on Pages 3 and 4 and send all four pages of the return to DRS.
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