Form Ct-1040nr/py - Connecticut Nonresident And Part-Year Resident Income Tax Return - 2015 Page 3

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Form CT-1040NR/PY
Your Social Security Number
Page 3 of 4
(Rev. 12/15)
NRPY 00 15W 03 9999
Schedule 1 - Modifi cations to Federal Adjusted Gross Income
Enter all items as positive numbers.
See instructions, Page 20.
.00
33. Interest on state and local government obligations other than Connecticut
33.
34. Mutual fund exempt-interest dividends from non-Connecticut state or municipal
.00
government obligations
34.
35. Taxable amount of lump-sum distributions from qualifi ed plans not included in federal
.00
adjusted gross income
35.
.00
36. Benefi ciary’s share of Connecticut fi duciary adjustment: Enter only if greater than zero.
36.
.00
37. Loss on sale of Connecticut state and local government bonds
37.
.00
38. Domestic production activity deduction from federal Form 1040, Line 35
38.
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39. Other - specify
39.
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40. Total additions: Add Lines 33 through 39. Enter here and on Line 2.
40.
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41. Interest on U.S. government obligations
41.
.00
42. Exempt dividends from certain qualifying mutual funds derived from U.S. government obligations
42.
.00
43. Social Security benefi t adjustment: See Social Security Benefi t Adjustment Worksheet, Page 22.
43.
.00
44. Refunds of state and local income taxes
44.
.00
45. Tier 1 and Tier 2 railroad retirement benefi ts and supplemental annuities
45.
.00
46. Military retirement pay
46.
.00
47. 10% of income received from the Connecticut teacher’s retirement system
47.
.00
48. Benefi ciary’s share of Connecticut fi duciary adjustment: Enter only if less than zero.
48.
.00
49. Gain on sale of Connecticut state and local government bonds
49.
.00
50. Connecticut Higher Education Trust (CHET) contributions
50.
Enter CHET account number:
Do not add spaces or dashes.
.00
51. Other - specify: Do not include out of state income.
51.
.00
52. Total subtractions: Add Lines 41 through 51. Enter here and on Line 4.
52.
Schedule 2 - Credit for Income Taxes Paid to Qualifying Jurisdictions - Part-Year Residents Only
You must attach a copy of your return fi led with the qualifying jurisdiction(s) or your credit will be disallowed. See instructions.
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53. Connecticut adjusted gross income during the residency portion of taxable year. ................. 53
See instructions, Page 26.
Column A
Column B
Name
Code
Name
Code
54. Enter qualifying jurisdiction’s name and two-letter code. ......................... 54.
See instructions, Page 26.
55. Non-Connecticut income included on Line 53 and reported on a qualifying
jurisdiction’s income tax return: Complete Schedule 2 Worksheet, Page 25. . 55.
.00
.00
.
.
56. Divide Line 55 by Line 53. May not exceed 1.0000. ................................. 56.
.00
.00
57. Apportioned income tax: See instructions, Page 26. .................................... 57.
.00
.00
58. Multiply Line 56 by Line 57. ...................................................................... 58.
.00
.00
59. Income tax paid to a qualifying jurisdiction. See instructions, Page 26. ... 59.
.00
.00
60. Enter the lesser of Line 58 or Line 59. ..................................................... 60.
.00
61. Total credit: Add Line 60, all columns. Enter here and on Line 11. ......................................... 61.
Complete applicable schedules on Page 4 and send all four pages of the return to DRS.

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