State of Connecticut
F F F F F or
or
or
orm CT
m CT
m CT-941X
m CT
-941X
-941X
-941X
or
m CT
-941X
Department of Revenue Services
(Rev. 12/03)
AMENDED CONNECTICUT RECONCILIATION OF WITHHOLDING
(Important: See instructions on back before completing this return.)
NAME OF EMPLOYER
CONNECTICUT TAX REGISTRATION NUMBER
ADDRESS (Number and Street)
FEDERAL EMPLOYER ID NUMBER
CITY, TOWN, or POST OFFICE
STATE
ZIP CODE
Name of form being amended (check one):
Form CT-941
Form CT-945
Form CT-941 (DRS/P) Household Employer
Calendar
Quarter being amended (Form CT-941 filers only, check one) and enter calendar year (all filers):
Year
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
January - March
April - June
July - September
October - December
_________________
AMOUNT AS ORIGINALLY
NET CHANGE
CORRECTED
REPORTED ON
(Increase or Decrease)
AMOUNT
CT-941 OR CT-945
1. Enter gross wages from Form CT-941, Line 1 or
gross nonpayroll amounts from Form CT-945, Line 1 ...... 1
2. Enter gross CT wages from Form CT-941, Line 2 or gross
CT nonpayroll amounts from Form CT-945, Line 2 ........... 2
3. Enter CT tax withheld from Form CT-941, or
Form CT-945, Line 3 ............................................................ 3
4. Enter credit from prior quarter, if any, of the same
calendar year (Form CT-941 filers only) ......................... 4
5. Deposits made with Form CT-WH (Form CT-941) or
Form CT-8109 (Form CT-945) ............................................. 5
6. Amount paid with Form CT-941, Form CT-945,
or Form CT-941 (DRS/P) ...................................................... 6
7. Total payments (Add Lines 4, 5, and 6) ............................ 7
8. Overpayment, if any, as shown on original return (or as previously adjusted) ...................................... 8
9. Subtract Line 8 from Line 7 ............................................................................................................................... 9
10. Net tax due or (credit) (Subtract Line 9 from Line 3) ................................................................................. 1 0
11. Interest on net tax due ...................................................................................................................................... 11
12. Total amount due or (credit) (Add Line 10 and Line 11) ........................................................................... 1 2
Overpayment:
$ ____________________
If amount on Line 12 is a credit, enter overpayment amount here
and
If Line 12 shows an amount due, make check payable to:
check if to be:
Applied to next return OR
Refunded
Commissioner of Revenue Services.
Write your CT Tax Registration Number on your check.
Declaration: I declare that (check the appropriate box)
All overwithheld Connecticut income taxes for the current calendar year
Mail to:
Department of Revenue Services
were repaid to employees prior to the end of the current calendar year.
State of Connecticut
(You must keep in your records each employee’s written receipt showing
PO Box 2931
the date and amount of repayment.)
Hartford CT 06104-2931
None of this refund or credit was withheld from employees.
Attach a copy of all applicable schedules and forms.
I further 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.
Signature of Employer
Date
Sign Here
Paid Preparer’s Signature
Date
Federal Employer ID Number
Keep a copy
of this return
Firm Name and Address
for your
records
Complete explanation of changes section on reverse