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Form CT-1040NR/PY - Page 2

Your Social

Security Number

19. Enter amount from Line 18.

19.

Column C

Column A

Column B

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

Connecticut Wages,

Connecticut Income Tax Withheld

Schedule

(Check box at left if from Schedule CT K-1)

federal ID No. from Schedule CT K-1, W-2G, or 1099

Tips, etc.

CT K-1

–

20a.

W-2, W-2G,

and 1099

–

20b.

Federal

Identification

–

20c.

Information

(Only enter

–

information

20d.

from your W-2,

–

W-2G,

20e.

Schedule CT

K-1, and 1099

–

20f.

forms if

Connecticut

–

20g.

income tax

was withheld.)

20h.

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

20h.

20. Total Connecticut Income Tax Withheld (Add amounts in Column C and enter here.) 20.

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

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

21.

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

22.

23. Total Payments (Add Lines 20, 21, and 22.)

23.

24. Overpayment (If Line 23 is more than Line 19, subtract Line 19 from Line 23.)

24.

25. Amount of Line 24 you want applied to your 2006 estimated tax

25.

26. Total Contributions of Refund to Designated Charities (From Schedule 4, Line 63) 26.

27. Refund (Subtract Lines 25 and 26 from Line 24.)

For faster refund, use Direct Deposit by completing Lines 27a, 27b, and 27c.

27.

27a. Type:

27b. Routing

27c. Account

checking

Number

savings

28. Tax Due (If Line 19 is more than Line 23, subtract Line 23 from Line 19.)

28.

29. If Late: Enter Penalty (Multiply Line 28 by 10% (.10).)

29.

30. If Late: Enter Interest (Multiply Line 28 by number of months or fraction of a month

late, then by 1% (.01).)

30.

31. Interest on underpayment of estimated tax (See instructions, Page 17.)

31.

32. Total Amount Due (Add Lines 28 through 31.)

32.

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 Pages 3 and 4.

Form Ct-1040nr/py - Connecticut Nonresident And Part-Year Resident Income Tax Return - 2005 Page 2

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