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Form CT-1040NR/PY - Page 2

Your Social

Security Number

19. Total Tax (enter amount from Line 18, on front of this return)

19.

COLUMN A

COLUMN B

COLUMN C

Employer Identification Number

Connecticut Wages, Tips, etc.

Connecticut Income Tax Withheld

20a.

W-2, W-2G,

and 1099

20b.

Identification

Information

20c.

(only enter

information

20d.

from your W-2,

W-2G, and

20e.

1099 forms

if Connecticut

20f.

income tax

20g.

was withheld).

Enter additional CT withholding from Schedule CT-1040WH, Line 3 20h.

20h.

20. Total Connecticut Income Tax Withheld (add the amounts in Column C and enter here) 20.

21. All 2004 estimated tax payments and any overpayments applied from a prior year

21.

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

22.

23. Total Payments (Add Lines 20, 21, and 22)

23.

24. Overpayment (If Line 23 is more than Line 19, subtract Line 19 from Line 23.)

24.

25. Amount of Line 24 you want applied to your 2005 estimated tax

25.

26a. AIDS

26b. Organ

Contributions

.00

Research

Transplant

26c. Endangered

24e. Safety

26d. Breast Cancer

26e. Safety

.00

Species/Wildlife

Net Services

Research

Net Services

26. Total Contributions of Refund to Designated Charities

(add amounts from Lines 26a - 26e)

26.

27. Refund (Subtract Lines 25 and 26 from Line 24) For faster refund, choose

Direct Deposit and complete Lines 27a, 27b, and 27c.

27.

27a. Type of Account:

27b. Routing Number

Checking

Savings

27c. Account Number

28. Tax Due (If Line 19 is more than Line 23, subtract Line 23 from Line 19)

28.

29. If Late: Enter Penalty (Multiply Line 28 by 10% (.10))

29.

30. If Late: Enter Interest (Multiply Line 28 by number of months late or fraction thereof,

then by 1% (.01))

30.

31. Interest on underpayment of estimated tax (from Form CT-2210, see instructions, Page 16) 31.

32. Total Amount Due (Add Lines 28 through 31)

32.

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 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

(

)

Spouse’s Signature (if joint return)

Date

Daytime Telephone Number

(

)

Paid Preparer’s Signature

Date

Telephone Number

Preparer’s SSN or PTIN

(

)

Firm’s Name, Address, and ZIP Code

FEIN

Third Party Designee - Complete the following if you wish to authorize DRS to contact another person about this return.

Designee’s Name

Telephone Number

Personal Identification Number (PIN)

Complete applicable Schedules on Pages 3 and 4.

Form CT-1040NR/PY Back (Rev. 12/04)

Form Ct-1040nr/py - Connecticut Nonresident Or Part-Year Resident Income Tax Return - 2004 Page 2

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