Form Ct-1040nr/py - Nonresident Or Part-Year Resident Income Tax Return

Schedule 1

Modifications to Federal Adjusted Gross Income (enter all amounts as positive numbers)

32. Interest on state and local government obligations other than Connecticut

33. Mutual fund exempt-interest dividends from non-Connecticut state or municipal government obligations

Additions

34. Special depreciation allowance for qualified property placed in service during this year

to Federal

35. Taxable amount of lump-sum distributions from qualified plans not included in federal adjusted gross income

Adjusted

Gross Income

36. Beneficiary’s share of Connecticut fiduciary adjustment (Enter only if greater than zero)

(See instructions,

37. Loss on sale of Connecticut state and local government bonds

Page 18)

38. Other - specify ____________________________________________________________________

39. TOTAL ADDITIONS (Add Lines 32 through 38) Enter here and on Line 2.

40. Interest on United States government obligations

41. Exempt dividends from certain qualifying mutual funds derived from United States government obligations

42. Social Security benefit adjustment (See Social Security Benefit Adjustment Worksheet, Page 19)

Subtractions

From Federal

43. Refunds of state and local income taxes

Adjusted

44. Tier 1 and Tier 2 railroad retirement benefits and supplemental annuities

Gross Income

45. Special depreciation allowance for qualified property placed in service during the preceding year

(See instructions,

46. Beneficiary’s share of Connecticut fiduciary adjustment (Enter only if less than zero)

Page 19)

47. Gain on sale of Connecticut state and local government bonds

48. Other - specify (Do not include out-of-state income) ______________________________________

49. TOTAL SUBTRACTIONS (Add Lines 40 through 48) Enter here and on Line 4.

Credit for Income Taxes Paid to Qualifying Jurisdictions (for Part-Year Residents Only)

Schedule 2

50. Connecticut AGI during the residency portion of the taxable year (See instructions, Page 23)

FOR EACH COLUMN, ENTER THE FOLLOWING:

COLUMN A

COLUMN B

Important:

Name

Code

Name

Code

You must

51. Enter qualifying jurisdiction’s name and two-letter code (See instructions, Page 23)

attach a copy

52. Non-Connecticut income included on Line 50 and reported on a qualifying

of your return

jurisdiction’s income tax return (Complete Schedule 2 Worksheet , Page 22)

filed with the

53. Divide Line 52 by Line 50 (may not exceed 1.0000)

qualifying

jurisdiction(s)

54. Apportioned income tax (See instructions, Page 23)

or your credit

55. Multiply Line 53 by Line 54

will be

56. Income tax paid to a qualifying jurisdiction (See instructions, Page 23)

disallowed.

57. Enter the lesser of Line 55 or Line 56

58. TOTAL CREDIT (Add Line 57, all columns) Enter here and on Line 11.

Schedule 3

Contributions of Refund to Designated Charities (See instructions, Page 24)

AIDS Research

___ $2

__ $5

_ $15

other ___ .00

Breast Cancer Research

___ $2

__ $5

_ $15

other ___ .00

Organ Transplant

___ $2

__ $5

_ $15

other ___ .00

Safety Net Services

___ $2

__ $5

_ $15

other ___ .00

Endangered Species/Wildlife

___ $2

__ $5

_ $15

other ___ .00

59. TOTAL CONTRIBUTIONS. Enter here and on Line 25.

Due Date: April 15, 2004

Make your check or money order payable to: “Commissioner of Revenue Services”

To ensure proper posting of your payment, write your Social Security Number(s) and “2003 Form CT-1040NR/PY” on your check or money order.

Attach a copy of all applicable schedules and forms to this return. 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

PO Box 2968

PO Box 2969

Hartford CT 06104-2968

Hartford CT 06104-2969

Do you authorize DRS to contact another person about this return? ( See Page 17)

Yes. Complete the following.

Third Party

Designee’s Name

Telephone Number

Personal Identification

Designee

(

)

Number (PIN)

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 that 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

Sign Here

(

)

Keep a copy

Spouse’s Signature (if joint return)

Date

Daytime Telephone Number

for your

(