Form Ct-1040nr/py - Connecticut Nonresident Or Part-Year Resident Income Tax Return - 2004 Page 3

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Form CT-1040NR/PY - Page 3
Your Social
Security Number
Schedule 1 - Modifications to Federal Adjusted Gross Income
(Enter all items as positive numbers.)
(See Instructions, Page 18)
,
,
. 00
33. Interest on state and local government obligations other than Connecticut
33.
34. Mutual fund exempt-interest dividends from non-Connecticut state or municipal
,
,
. 00
government obligations
34.
,
,
. 00
35. Special depreciation allowance for qualified property placed in service prior to Sept. 11, 2004 35.
36. Taxable amount of lump-sum distributions from qualified plans not included in federal
,
,
. 00
adjusted gross income
36.
,
,
. 00
37. Beneficiary's share of Connecticut fiduciary adjustment (Enter only if greater than zero)
37.
,
,
. 00
38. Loss on sale of Connecticut state and local government bonds
38.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
39. Allocated for future use
39.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
,
,
. 00
40. Other - specify
________________________________________________________
40.
,
,
. 00
41. Total Additions (Add Lines 33 through 40) Enter here and on Line 2.
41.
,
,
. 00
42. Interest on U.S. government obligations
42.
,
,
. 00
43. Exempt dividends from certain qualifying mutual funds derived from U.S. government obligations 43.
44. Social Security benefit adjustment
,
,
. 00
(See Social Security Benefit Adjustment Worksheet, Page 19)
44.
,
,
. 00
45. Refunds of state and local income taxes
45.
,
,
. 00
46. Tier 1 and Tier 2 railroad retirement benefits and supplemental annuities
46.
,
,
. 00
47. Special depreciation allowance for qualified property placed in service during the preceding year
47.
,
,
. 00
48. Beneficiary's share of Connecticut fiduciary adjustment (Enter only if less than zero)
48.
,
,
. 00
49. Gain on sale of Connecticut state and local government bonds
49.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
50. Allocated for future use
50.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
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. 00
51. Other - specify (Do not include out of state income)
____________________________
51.
,
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. 00
52. Total Subtractions (Add Lines 42 through 51) Enter here and on Line 4.
52.
Schedule 2 - Credit for Income Taxes Paid to Qualifying Jurisdictions - Part-Year Residents Only
(You must attach a copy of your return filed with the qualifying jurisdiction(s) or your credit will be disallowed.)
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. 00
53.
53. Connecticut AGI during residency portion of taxable year (See instructions, Page 23)
COLUMN A
COLUMN B
Name
Code
Name
Code
54. Enter qualifying jurisdiction's name and two-letter code
(See instructions, Page 23)
54.
55. Non-Connecticut income included on Line 53 and
reported on a qualifying jurisdiction's income tax return
,
,
. 00
,
,
. 00
(Complete Schedule 2 Worksheet, Page 22)
55.
.
.
56. Divide Line 55 by Line 53 (may not exceed 1.0000)
56.
,
,
. 00
,
,
. 00
57. Apportioned income tax (See instructions, Page 23)
57.
,
,
. 00
,
,
. 00
58. Multiply Line 56 by Line 57
58.
59. Income tax paid to a qualifying jurisdiction
,
,
. 00
,
,
. 00
(See instructions, Page 24)
59.
,
,
. 00
,
,
. 00
60. Enter the lesser of Line 58 or Line 59
60.
,
,
. 00
61. Total Credit (Add Line 60, all columns) Enter here and on Line 11. 61.
Complete applicable Schedule on Page 4.

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