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2001

STATE OF CONNECTICUT

FORM CT-1040 EXT

DEPARTMENT OF REVENUE SERVICES

EXT

Application for Extension of Time to File

Connecticut Income Tax Return for Individuals

IMPORTANT! PLEASE READ INSTRUCTIONS ON REVERSE BEFORE COMPLETING THIS FORM.

Your First Name and Middle Initial

Last Name

Your Social Security Number

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If a JOINT Return, Spouse’s First Name and Middle Initial

Last Name

Spouse’s Social Security Number

TAXPAYER

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(Please Type

Home Address (number and street), Apartment Number, PO Box

Daytime Telephone Number

(

)

or Print)

City, Town, or Post Office

State

ZIP Code

DEPARTMENT USE ONLY

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Use WebFile (available April 1, 2002) to request an extension of time to file and do not send in

Form CT-1040 EXT. For details, visit the DRS Web site at:

This is not an extension of time to pay your tax.

You must file this form by the due date of your original return or your extension request will be denied (See instructions).

You will be subject to interest and penalty on any amount of tax that is not paid by the original due date of your return.

An extension granted by the Internal Revenue Service does not automatically extend the Connecticut filing date.

I request a six-month extension of time to October 15, 2002, to file my Connecticut Income Tax Return for the year beginning

January 1, 2001, and ending December 31, 2001.

If you are not a calendar year taxpayer, complete the following statement:

I request a six-month extension of time to _________________________________ to file my Connecticut Income Tax Return

for the year beginning ___________________________ and ending

_________________________________

I have requested a federal extension on federal Form 4868, Application for Automatic Extension of Time to File U.S. Individual Income

Tax Return , for taxable year 2001.

YES

If NO, the reason for the Connecticut extension is ____________________________________________________________________

_____________________________________________________________________________________________________________

YOU WILL BE NOTIFIED ONLY IF YOUR EXTENSION REQUEST IS DENIED

Total income tax liability for 2001.

You must enter an amount on Line 1. If you do not expect to owe income tax, enter “0” .................. 1.

2. Total individual use tax liability for 2001.

You must enter an amount on Line 2. If you do not expect to owe use tax, enter “0” ........................ 2.

3. Add Line 1 and Line 2 ............................................................................................................................... 3.

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3

4. Connecticut income tax withheld (Do not attach W-2s or 1099s) ........ 4.

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3

5. 2001 estimated Connecticut income tax payments including any

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3

2000 overpayments credited to 2001 ....................................................... 5.

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3

6. Add Line 4 and Line 5 ............................................................................................................................... 6.

7. Connecticut income tax and use tax balance due. (Subtract Line 6 from Line 3)

If Line 6 is greater than Line 3, enter “0.” Amount due with this form ............................................

Remember to include your name(s), mailing address, and Social Security Number(s) at the top of this form.

Pay by credit card (see instructions) or

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

Write your Social Security Number(s) and “2001 Form CT-1040 EXT” on your check or money order.

For forms with payment mail to:

For forms without payment mail to:

Department of Revenue Services

PO Box 2977

PO Box 2976

Hartford CT 06104-2977