Form Ct-1040nr/py - Connecticut Nonresident Or Part-Year Resident Income Tax Return - 2004 Page 4

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Form CT-1040NR/PY - Page 4
Your Social
Security Number
Schedule 3 - INDIVIDUAL USE TAX WORKSHEET
Complete this worksheet to calculate your Connecticut Individual Use Tax liability.
COLUMN A
COLUMN B
COLUMN C
COLUMN D
COLUMN E
COLUMN F
COLUMN G
TAX, IF ANY,
BALANCE DUE
DATE OF
DESCRIPTION OF GOODS
RETAILER OR SERVICE
PURCHASE
PAID TO
CT TAX DUE
(Column E minus
PURCHASE
OR SERVICES
PROVIDER
PRICE
ANOTHER
(.06 X Column D)
Column F but not
JURISDICTION
less than zero)
Total of individual purchases under $300 not listed above
62. Individual Use Tax (Add all amounts for Column G.) Enter here and on
00
.
,
Form CT-1040NR/PY, Line 17.
62.
Use envelope provided, with correct mailing label, or mail to:
Make your check or money order payable to:
For refunds and all other tax forms without payment:
For all tax forms with payment:
“Commissioner of Revenue Services”
Department of Revenue Services
Department of Revenue Services
To ensure proper posting, write your SSN(s)
PO Box 2968
PO Box 2969
and “2004 Form CT-1040NR/PY” on your
Hartford CT 06104-2969
Hartford CT 06104-2968
check or money order.

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