Form Ct-1040nr/py - Connecticut Nonresident And Part-Year Resident Income Tax Return - 2009 Page 4

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Form CT-1040NR/PY - Page 4 of 4
Your Social
-
-
Security Number
Schedule 3 - Individual Use Tax - Do you owe use tax?
See instructions, Page 36.
Complete this schedule to calculate your Connecticut individual use tax liability and attach it to your return.
Column G
Column A
Column B
Column C
Column D
Column E
Column F
Tax, if any,
Balance due
paid to
(Column E minus
CT tax due
Date of
Description of
Retailer or
Purchase
another
Column F but not
(.06 X Column D)
purchase
goods or services
service provider
price
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 - Contributions to Designated Charities
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 payable to: Commissioner of Revenue Services
To ensure proper posting, write your SSN(s) (optional) and “2009 Form CT-1040NR/PY” on your check.
Complete all applicable schedules on Pages 3 and 4
and attach the schedules to your return.

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