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

STATE OF CONNECTICUT

DEPARTMENT OF REVENUE SERVICES

Check here for 2000 resident status:

Nonresident

Part-Year Resident

For the year January 1 - December 31, 2000, or other taxable year

beginning _____________, 2000,

ending _____________, _____.

Your First Name and Middle Initial

Last Name

Social Security Number

__ __ __

__ __

__ __ __ __

• •

Use the

Spouse’s Social Security Number

If a JOINT Return, Spouse’s First Name and Middle Initial

Last Name

__ __ __

__ __

__ __ __ __

DRS label

• •

located on

IMPORTANT!

cover.

Home Address (number and street)

PO Box

Apt. No.

You MUST enter your SSN(s) above.

Otherwise,

City, Town or Post Office

State

ZIP Code

DEPARTMENT USE ONLY

or type.

(See

instructions,

Check here if you do not want forms sent to you next year. Checking this box does not relieve you of your responsibility to file ...............

Page 14)

If you are required to file Form CT-2210 and checked any boxes on Part 1 of that form, check here .............................................................

A .

Single

Married filing joint return or Qualifying widow(er) with dependent child

• •

__ __ __ __ __ __ __ __ __

• •

Married filing SEPARATE return

Check only

Spouse’s full name

Spouse’s Social Security Number

one box.

Head of household (with qualifying person)

1. Federal Adjusted Gross Income (from federal Form 1040, Line 33; Form 1040A, Line 19;

Form 1040EZ, Line 4; or federal TeleFile Tax Record, Line I)

2. Additions, if any (from Schedule 1 , Line 39, on reverse)

3. Add Line 1 and Line 2

Income

4. Subtractions, if any (from Schedule 1 , Line 49, on reverse)

5. Connecticut Adjusted Gross Income (Subtract Line 4 from Line 3)

6. Income from Connecticut sources (from Schedule CT-SI , Line 26)

(If zero or less, go to Line 12 and enter “0.”)

8. Income Tax: From Tax Tables or Tax Calculation Schedule (See instructions, Page 15)

9. Divide Line 6 by Line 5 (If Line 6 is equal to or greater than Line 5, enter 1.0000)

10. Multiply Line 9 by Line 8

11. Credit for income taxes paid to qualifying jurisdictions by part-year residents only (from Schedule 2 )

12. Subtract Line 11 from Line 10 (If Line 11 is greater than Line 10, enter “0.”)

13. Connecticut Alternative Minimum Tax (from Form CT-6251)

Tax

14. Add Line 12 and Line 13

15. Adjusted Net Connecticut Minimum Tax Credit (from Form CT-8801)

16.

(Subtract Line 15 from Line 14. If less than zero, enter “0.”)

17.

(Complete the Individual Use Tax Worksheet.) You must enter zero

on this line if no use tax is due. (See instructions, Page 16)

18.

(Add Line 16 and Line 17)

19. Connecticut tax withheld (Attach all W-2s and certain 1099s; see instructions, Page 16 )

20. All 2000 estimated tax payments and any overpayments applied from a prior year

Payments

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

22.

(Add Lines 19, 20, and 21)

23. If Line 22 is greater than Line 18, enter amount overpaid. (Subtract Line 18 from Line 22)

24. Amount of Line 23 you want applied to your 2001 estimated tax

25. Amount of Line 23 you want to contribute to: (See instructions, Page 17)

AIDS Research

____ $2

____ $5

______ $15

other ____________ .00

Organ Transplant

____ $2

____ $5

______ $15

other ____________ .00

Endangered Species/Wildlife

____ $2

____ $5

______ $15

other ____________ .00

Refund

Breast Cancer Research

____ $2

____ $5

______ $15

other ____________ .00

Safety Net Services

____ $2

____ $5

______ $15

other ____________ .00

26. Amount of Line 23 you want refunded to you. (Subtract Line 24 and Line 25 from Line 23) REFUND

27. If Line 18 is greater than Line 22, enter the amount of tax you owe. (Subtract Line 22 from Line 18)

28. If late: Enter Penalty (Multiply Line 27 by 10% (.10))

Amount

29. If late: Enter Interest (Multiply Line 27 by number of months late or fraction thereof, then by 1% (.01))

You Owe

30. Interest on underpayment of estimated tax (from Form CT-2210; see instructions, Page 17 )

31. Amount you owe with this return (Add Lines 27 through 30)

SEE PAYMENT AND MAILING INSTRUCTIONS ON REVERSE

TAXPAYERS MUST SIGN DECLARATION ON REVERSE

Form Ct-1040nr/py - Nonresident And Part-Year Resident Income Tax Return - 2000

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