Form Ct-1127 - Application For Extension Of Time For Payment Of Income Tax

2003

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orm CT-1127

m CT-1127

Department of Revenue Services

State of Connecticut

25 Sigourney Street

Application for Extension

Hartford CT 06106-5032

of Time for Payment of Income Tax

(Rev. 12/03)

Place this form on TOP of your completed return.

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

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)

or Print)

City, Town, or Post Office

State

ZIP Code

DRS USE ONLY

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IMPORTANT! PLEASE READ THE INSTRUCTIONS ON THE BACK OF THIS FORM.

This form is not an extension of time to file.

See How to Get an Extension of Time to File (on back) for additional time to file.

You must file this form on or before the due date of your return or your extension request will be denied.

I request a six-month extension of time to October 15, 2004, to pay my Connecticut Income Tax of $ _______________ for the year

beginning January 1, 2003, and ending December 31, 2003.

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

I request a six-month extension of time to __________________________ , to pay my Connecticut Income Tax of $ _______________

for the year beginning ________________________ and ending

________________________________ .

This extension is necessary and payment of the tax at this time will cause me undue hardship because: (If more space is needed,

please attach a separate sheet) __________________________________________________________________________

__________________________________________________________________________________________________

I am unable to borrow money to pay the tax because: __________________________________________________________

__________________________________________________________________________________________________

As evidence of the need for the extension, I am attaching: (1) a statement of assets (including all bank accounts, receivables,

notes, stocks, bonds, cash value life insurance, automobiles, and real estate) and liabilities as of the last day of the preceding

month (showing book and market values of assets and whether any securities are listed or unlisted); and (2) an itemized list of

receipts (income) and disbursements (expenses) for the three months before the date the tax is due.

— YOU WILL BE NOTIFIED ONLY IF YOUR EXTENSION REQUEST IS DENIED —

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 that 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

SIGN

Spouse’s Signature

Date

HERE

Paid Preparer’s Signature

Date

Telephone

Preparer’s SSN or PTIN

Keep a