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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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)