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

(See instructions, Page 18)

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

33. Exempt-interest dividends from a mutual fund derived from state or municipal government obligations

other than Connecticut

34. Shareholder’s pro rata share of S corporation nonseparately computed loss

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

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

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

38. Other - specify ______________ ______________________________________________________________

39. TOTAL ADDITIONS (Add Lines 32 through 38) Enter here and on Line 2 on the front of this form.

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 20)

43. Refunds of state and local income taxes

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

45. Shareholder’s pro rata share of S corporation nonseparately computed income

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

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 on the front of this form.

IMPORTANT: You must attach a copy of your return filed with the qualifying jurisdiction(s) or the credit will be disallowed.

50. Connecticut AGI during the residency portion of the taxable year (See instructions, Page 24)

FOR EACH COLUMN, ENTER THE FOLLOWING:

Name

Code

Name

Code

51. Enter qualifying jurisdiction’s name and two-letter code (See instructions, Page 24) 51

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

jurisdiction’s income tax return (Complete Schedule 2 Worksheet , Page 23)

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

54. Apportioned income tax ( See instructions, Page 24)

55. Multiply Line 53 by Line 54

56. Income tax paid to a qualifying jurisdiction ( See instructions, Page 24)

57. Enter the lesser of Line 55 or Line 56

58. TOTAL CREDIT (Add Line 57, all columns)

Enter this amount here and on Line 11 on the front of this form.

Make your check or money order payable to: COMMISSIONER OF REVENUE SERVICES,

and write your Social Security Number(s) and “2000 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 refund request or no tax due – Department of Revenue Services

For payment – Department of Revenue Services

PO Box 2968

PO Box 2969

Hartford CT 06104-2968

Hartford CT 06104-2969

I declare under the penalties of false statement 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. The penalties for false statement are imprisonment not to exceed one year or a fine not to exceed two thousand

dollars, or both. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Your Signature

Date

Daytime Telephone Number

May DRS contact the preparer

Sign

(

)

shown below about this return?

Here

(see Page 18)

Spouse’s Signature (if joint return)