Department of Revenue Services
State of Connecticut
25 Sigourney St Ste 2
Hartford CT 06106-5032
Application for Extension of Time for Payment of Income Tax
Place this form on top of your completed Connecticut income tax return. Complete in blue or black ink only.
This form is not an extension of time to ﬁ le. See How to Get an Extension of Time to File (on back) for additional information.
You must ﬁ le this form on or before the due date of your return or your extension request will be denied.
Your ﬁ rst name and middle initial
Your Social Security Number (SSN)
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If a joint return, spouse’s ﬁ rst name and middle initial
Spouse’s Social Security Number
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Name of estate, trust, partnership, or entity
Federal Employer Identiﬁ cation Number
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Mailing address (number and street), apartment number, PO box
Daytime telephone number
DRS use only
City, town, or post ofﬁ ce
I request a six-month extension of time to October 15, 2015, to pay my Connecticut income tax of $ _______________
for the year beginning January 1, 2014, and ending December 31, 2014.
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, 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 notiﬁ ed only if your extension request is denied.
Declaration: 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 the penalty for willfully delivering a false return
or document to the Department of Revenue Services (DRS) is a ﬁ ne of not more than $5,000, imprisonment for not more than ﬁ ve 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.
Paid preparer’s signature
Preparer’s SSN or PTIN
Firm’s name, address, and ZIP code