Form Ct-990t - Connecticut Unrelated Business Income Tax Return - 2016
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1
2
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4Department of Revenue Services
Form CT-990T
2016
State of Connecticut
Connecticut Unrelated Business
(Rev. 12/16)
Income Tax Return
990T 1216W 01 9999
Complete this return in blue or black ink only.
For DRS
2016
Enter Income Year Beginning
and Ending
Use Only
M M - D D - Y Y Y Y
M M - D D - Y Y Y Y
M M - D D - Y Y Y Y
Organization name
Connecticut Tax Registration Number
Number and street
PO Box
Federal Employer ID Number (FEIN)
City, town, or post offi ce
State
ZIP code
Check All Applicable Boxes:
Organization is annualizing its income.
Change of:
Mailing address
Closing month (Attach explanation.)
Return status:
Amended return
Initial return
Final return
If fi nal return:
Dissolved
Withdrawn
Merged/reorganized:
Enter survivor’s CT Tax Reg. Number.
Type of organization:
Corporation
Domestic trust
Foreign trust
Other: Explain
1. Date unrelated trade or business began in Connecticut:
M
M
-
D
D
-
Y
Y
Y
Y
2. Nature of unrelated trade or business income activity:
3. Corporation only: Enter state of incorporation:
Date of organization:
M
M
-
D
D
-
Y
Y
Y
Y
Date qualifi ed in Connecticut if not incorporated in Connecticut:
M
M
-
D
D
-
Y
Y
Y
Y
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 the Department of Revenue Services (DRS) is a fi ne of not more than $5,000, 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.
Name of offi cer or fi duciary (print)
Signature of offi cer or fi duciary
Date
(MMDDYYYY)
Offi cer’s email address (print)
Sign
Here
Title
Telephone number
Keep a
May DRS contact the preparer
copy of
Yes
No
shown below about this return?
this
Paid preparer’s name (print)
Paid preparer’s signature
Date
Preparer’s SSN or PTIN
(MMDDYYYY)
return
for your
records.
Firm’s name and address
Firm’s FEIN
Telephone number
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