Form Ct-1040nr/py - Connecticut Nonresident And Part-Year Resident Income Tax Return - 2005 Page 4

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Form CT-1040NR/PY - Page 4
Your Social
-
-
Security Number
Schedule 3 - Individual Use Tax Worksheet
Complete this worksheet to calculate your Connecticut individual use tax liability.
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Tax, if any,
Balance due
Date of
Description of goods or
Retailer or service
Purchase price
CT tax due
paid to
(Column E minus
purchase
services
provider
another
(.06 X Column D)
Column F but not
jurisdiction
less than zero)
Total of individual purchases under $300 not listed above
00
.
,
62. Individual Use Tax (Add all amounts for Column G.) Enter here and on Line 17.
62.
Schedule 4 - Contribution Worksheet
.
00
63a. AIDS Research
63a.
,
,
.
00
63b. Organ Transplant
63b.
,
,
.
00
63c. Endangered Species/Wildlife
63c.
,
,
.
00
63d. Breast Cancer Research
63d.
,
,
.
00
63e. Safety Net Services
63e.
,
,
.
00
63f.
Military Family Relief Fund
63f.
,
,
.
00
63.
Total Contributions (Add Lines 63a through 63f, enter amount here and on Line 26.)
63.
,
,
Use envelope provided, with correct mailing label, or mail to:
For refunds and all other tax forms without payment:
For all tax forms with payment:
Department of Revenue Services
Department of Revenue Services
PO Box 2968
PO Box 2969
Hartford CT 06104-2968
Hartford CT 06104-2969
Make your check or money order payable to: Commissioner of Revenue Services
To ensure proper posting, write your SSN(s) and “2005 Form CT-1040NR/PY” on your check or money order.

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