Form Ct-1040x - Amended Connecticut Income Tax Return For Individuals - 2015
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12Department of Revenue Services
Form CT-1040X
2015
State of Connecticut
Amended Connecticut Income
(Rev. 12/15)
1040X 00 15W 01 9999
Tax Return for Individuals
Complete this form in blue or black ink only. Type or print.
For January 1 - December 31, 2015,
(MMDDYYYY) and Ending
(MMDDYYYY).
or other taxable year Year Beginning
Your fi rst name
Middle initial
Last name
Deceased
Your Social Security Number (SSN)
If joint return,
spouse’s fi rst name
Middle initial
Last name
Deceased
Spouse’s SSN
Mailing address (number and street)
Mailing address 2 (apartment number, PO Box)
City, town, or post offi ce
State
ZIP code
Your telephone number
City or town of residence if different from above
ZIP code
DRS use only
(MMDDYYYY)
Filing Status
On original return:
Single
Head of household
Married fi ling jointly
Qualifying widow(er)
Married fi ling separately
On this return:
Single
Head of household
Married fi ling jointly
Qualifying widow(er)
Married fi ling separately
Check the box below if you are amending your return as a result of federal or another state’s changes to your income tax return or
because you fi led a timely-amended federal or other state’s return. Enter the date of the federal or other state’s fi nal determination below.
See instructions on Page 7.
Federal or state changes
Date:
(MMDDYYYY)
You must attach a copy of the IRS audit or other state’s results, federal Form 1040X, Form 1045, the other state’s amended return, supporting
documentation, and proof of the fi nal determination.
Check if fi ling Form CT-1040CRC, Claim of Right Credit
Check if fi ling Form CT-8379, Nonobligated Spouse Claim
Declaration: I declare under the penalty of law that I have examined this return 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.
Your signature
Date
Home/cell telephone number
Your email address
Sign Here
Spouse’s signature (if joint return)
Date (MMDDYYYY)
Daytime telephone number
Keep a
copy of
Paid preparer’s signature
Date (MMDDYYYY)
Telephone number
this return
for your
records.
Preparer’s SSN or PTIN
Firm’s Federal Employer Identifi cation Number (FEIN)
Firm’s name, address, and ZIP code
Make your check payable to Commissioner of Revenue Services. To ensure
Mail to:
Department of Revenue Services
proper posting of your payment, write your Social Security Number(s) (SSN)
PO Box 2978
(optional) and “2015 Form CT-1040X” on your check. The Department of
Hartford CT 06104-2978
Revenue Services (DRS) may submit your check to your bank electronically.
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