Form Op-305 - Application For Tax Amnesty - Connecticut Department Of Revenue Services, 2002 Page 2

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Name ______________________________ Social Security Number ________________________ CT Tax Registration Number _____________________
Schedule A
- Taxes Owed for Which No Return Has Been Filed
Important: You may be denied amnesty if you do not complete all appropriate sections.
List separately all taxable periods for which you are requesting amnesty. Only taxable periods ending on or before March 31, 2002, are eligible for amnesty.
Interest: Interest is computed at .75% (.0075) per month or fraction of a month. See Form OP-305 I, Instructions to Complete Application for Tax Amnesty
2002 , for more information.
If the space provided in Part 1, Part 2, or Part 3 is insufficient, attach supplementary schedules using the same format.
Part 1: Connecticut Income Tax Only
Filing Status
•
Attach appropriate W-2s to verify tax withheld. If you do not have a W-2, you must provide your employer’s name and address below.
A . Single
B . Married Filing Joint or
Employer’s Name _____________________________________ Employer’s Address _________________________________________
Qualifying Widow(er)
C . Married Filing Separate
•
Choose Filing Status from the box on the right and enter in Column 1.
D . Head of Household
E . Filers of CT-1041, CT-G,
•
Refer to the instructions to determine the correct amount to enter in Column 3.
CT-1120SI, CT-1065
Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Column 7
Column 8
Filing
Taxable
Total Tax
Connecticut Tax
Prepayments
Net Tax Due
Interest
Total
Status
Year
(See instructions)
Col. 3 - (Col. 4 + Col. 5)
(See Instructions)
(Col. 6 + Col. 7)
Withheld (Attach W-2s)
Total Part 1 (Add all amounts in Column 8)
Part 2: Connecticut Withholding Tax Only (Employers Only)
Column 2
Column 3
Column 4
Column 1
Column 5
Column 6
Total Deposited
Net Tax Due
Period Ending
Connecticut
Interest
Total
(Col. 2 - Col. 3)
Month
Year
Tax Withheld
(See Instructions)
(Col. 4 + Col. 5)
(MM)
(YY)
Total Part 2 (Add all amounts in Column 6)
Part 3: All Other Connecticut Taxes
(Sales and Use Taxes; Business Use Tax; Individual Use Tax; Room Occupancy Tax; Corporation Business Tax; Admissions, Dues
and Cabaret Tax; Fuel Taxes; Cigarette Taxes; Real Estate Conveyance Tax; etc.)
Column 1
Column 3
Column 4
Column 2
Column 5
Tax Type
Tax Due
Interest
Period Ending
Total
(See Instructions)
Month
Year
(Col. 3 + Col. 4)
(MM)
(YY)
Total Part 3 (Add all amounts in Column 5)
Total Schedule A: Add totals of Schedule A, Part 1, Part 2, and Part 3. Enter here and on Page 1, Line 10.
Page 2

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