Form Ct-1040 - Connecticut Resident Income Tax Return - 2004 Page 2
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1
2
3
4Form CT-1040 - Page 2
Your Social
Security Number
.
00
17. Total Tax (enter amount from Line 16, on front of this return)
17.
,
,
COLUMN A
COLUMN B
COLUMN C
Employer Identification Number
Connecticut Wages, Tips, etc.
Connecticut Income Tax Withheld
.
.
00
,
,
18a.
18a.
00
W-2, W-2G,
and 1099
.
.
00
,
,
18b.
18b.
00
Identification
Information
.
.
00
,
,
18c.
18c.
00
(only enter
.
.
00
information
,
,
18d.
18d.
00
from your W-2,
.
.
00
,
,
W-2G, and
18e.
18e.
00
1099 forms
00
.
.
,
,
if Connecticut
18f.
18f.
00
income tax
00
.
.
,
,
18g.
18g.
was withheld).
00
00
.
,
,
Enter additional CT withholding from Schedule CT-1040WH, Line 3 18h.
18h.
00
.
,
,
18. Total Connecticut Income Tax Withheld (add the amounts in Column C and enter here) 18.
00
.
,
,
19. All 2004 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 file)
20.
00
.
,
,
21. Total Payments (Add Lines 18, 19, and 20)
21.
.
00
,
,
.
22. Overpayment (If Line 21 is more than Line 17, subtract Line 17 from Line 21.)
22.
,
,
.
00
,
,
23. Amount of Line 22 you want applied to your 2005 estimated tax
23.
24a. AIDS
24b. Organ
Contributions
,
,
.00
,
,
.00
Research
Transplant
24c. Endangered
24e. Safety
24d. Breast Cancer
24e. Safety
,
,
.00
,
,
.00
,
,
.00
Species/Wildlife
Net Services
Research
Net Services
24. Total Contributions of Refund to Designated Charities
.
00
,
,
(add amounts from Lines 24a - 24e)
24.
25. Refund (Subtract Lines 23 and 24 from Line 22) For faster refund, choose
.
00
,
,
Direct Deposit and complete Lines 25a, 25b, and 25c.
25.
25a. Type of Account:
25b. Routing Number
Checking
Savings
25c. Account Number
.
00
,
,
26. Tax Due (If Line 17 is more than Line 21, subtract Line 21 from Line 17)
26.
.
00
,
,
27. If Late: Enter Penalty (Multiply Line 26 by 10% (.10))
27.
28. If Late: Enter Interest (Multiply Line 26 by number of months late or fraction thereof,
00
.
,
,
then by 1% (.01))
28.
.
00
,
,
29. Interest on underpayment of estimated tax (from Form CT-2210, see instructions, Page 17) 29.
00
.
,
,
30. Total Amount Due (Add Lines 26 through 29)
30.
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 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)
Form CT-1040 Back (Rev. 12/04)
Complete applicable Schedules on Form CT-1040 - Pages 3 and 4.
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