Form Ct-1065/ct-1120si - Supplemental Attachment Page 2

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Part IV – Member Information
Loss
Profi t
Capital
Member
Sharing %
Sharing %
Ownership %
Member Name and Address
Member
FEIN or SSN
Enter as a
Type
Enter as a
Enter as a
#
See instructions for order in which to list and for member type codes.
decimal.
decimal.
decimal.
Code
·
·
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·
·
·
·
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Part V – Member’s Share of Connecticut Modifi cations
Member
Member
Member
Member
# ________
# ________
# ________
# ________
Additions: Enter all amounts as positive numbers.
1. Interest on state and local government

00

00

00

00
obligations other than Connecticut ....................
1.
2. Mutual fund exempt-interest dividends
from non-Connecticut state or municipal
00 


00

00

00
government obligations .....................................
2.
3. Certain deductions relating to income

00

00
 
00

00
exempt from Connecticut income tax ............
3.
4. Reserved for future use .................................
4.
 
00

00

00

00
5. Other - specify: ________________________
5.
Subtractions: Enter all amounts as positive numbers.
 
00

00

00

00
6. Interest on U.S. government obligations ...........
6.
7. Exempt dividends from certain qualifying
mutual funds derived from U.S.

00

00

00

00
government obligations .....................................
7.
8. Certain expenses related to income exempt
from federal income tax but subject to




00
00
00
00
Connecticut tax .................................................
8.
9. Reserved for future use ...................................
9.

00

00

00

00
10. Other - specify: ________________________ 10.
Page 2 of 3
Form CT-1065/CT-1120SI Supplemental Attachment (Rev. 12/11)

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