Form Ct-1040x - Amended Connecticut Income Tax Return For Individuals - 2015 Page 4
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12Form CT-1040X
Your Social Security Number
Page 4 of 5
(Rev. 12/15)
1040X 00 15W 04 9999
Reason(s) for amending return: Enter the line number for each item you are changing and give the reason for each change in the space below.
Attach supporting forms and schedules for items changed. Write your name and SSN(s) on all attachments.
Schedule 1 - Modifi cations to Federal Adjusted Gross Income
Enter all amounts as positive numbers.
Additions to Federal Adjusted Gross Income
.00
31. Interest on state and local government obligations other than Connecticut. ................................................... 31.
32. Mutual fund exempt-interest dividends from non-Connecticut state or municipal government
.00
obligations other than Connecticut. ................................................................................................................. 32.
33. Taxable amount of lump-sum distributions from qualifi ed plans not included in federal adjusted
.00
gross income. .................................................................................................................................................. 33.
.00
34. Benefi ciary’s share of Connecticut fi duciary adjustment: Enter only if greater than zero. ............................... 34.
.00
35. Loss on sale of Connecticut state and local government bonds. .................................................................... 35.
.00
36. Domestic production activity deduction from federal form 1040, Line 35. ....................................................... 36.
.00
37. Other - specify.
37.
38. Total additions: Add Lines 31 through 37.
.00
Enter here and on Page 2, Line 2, Column C. ............................................................................................. 38.
Subtractions From Federal Adjusted Gross Income
.00
39. Interest on U.S. government obligations. ........................................................................................................ 39.
.00
40. Exempt dividends from certain qualifying mutual funds derived from U.S. government obligations. .............. 40.
.00
41. Social Security benefi t adjustment from Social Security Benefi t Adjustment Worksheet. ............................... 41.
.00
42. Refunds of state and local income taxes. ........................................................................................................ 42.
.00
43. Tier 1 and Tier 2 railroad retirement benefi ts and supplemental annuities. ..................................................... 43.
.00
44. Military retirement pay. .................................................................................................................................... 44.
.00
45. 10% of income received from the Connecticut teacher’s retirement system. .................................................. 45.
.00
46. Benefi ciary’s share of Connecticut fi duciary adjustment: Enter only if less than zero.. ................................... 46.
.00
47. Gain on sale of Connecticut state and local government bonds. .................................................................... 47.
48. Contributions to a Connecticut Higher Education Trust (CHET) account
.00
Enter CHET account number:
... 48.
Do not add spaces or dashes.
.00
49. Other - specify: Do not include out-of-state income
.
... 49.
.00
50. Total subtractions: Add Lines 39 through 49. Enter here and on Line 4, Column C. ................................ 50.
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