Form Ct-1040nr/py - Connecticut Nonresident And Part-Year Resident Income Tax Return - 2015 Page 4

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Form CT-1040NR/PY
Your Social Security Number
Page 4 of 4
(Rev. 12/15)
NRPY 00 15W 04 9999
Failure to report and pay use tax is subject to as much as a
$5,000 fi ne, imprisonment for as much as 5 years, or both.
Schedule 3 - Individual Use Tax
Do you owe use tax for online or other purchases where you paid no sales tax?
See instructions, Page 36.
Complete the Connecticut Individual Use Tax Worksheet on Page 37 to calculate your use tax liability.
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62a. Total use tax due at 1%: From Connecticut Individual Use Tax Worksheet, Section A, Column 7
62a.
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62b. Total use tax due at 6.35%: From Connecticut Individual Use Tax Worksheet, Section B, Column 7
62b.
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62c. Total use tax due at 7.75%: From Connecticut Individual Use Tax Worksheet, Section C, Column 7
62c.
62. Individual use tax: Add Lines 62a through 62c. If no use tax is due, you must enter “0.”
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Enter here and on Line 17.
62.
Schedule 4 - Contributions to Designated Charities
- See more information on Page 55.
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63a. AIDS Research
63a.
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63b. Organ Transplant
63b.
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63c. Endangered Species/Wildlife
63c.
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63d. Breast Cancer Research
63d.
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63e. Safety Net Services
63e.
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63f. Military Relief
63f.
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63g. CHET Baby Scholar
63g.
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63. Total Contributions: Add Lines 63a through 63g. Enter amount here and on Line 26a.
63.
Complete and send all four pages of the return to DRS.
Use the correct mailing address for returns with a payment or requesting a refund.
For refunds and all other tax forms without payment:
For all tax forms with payment:
Department of Revenue Services
Department of Revenue Services
PO Box 2968
PO Box 2969
Hartford CT 06104-2968
Hartford CT 06104-2969
Make your check payable to: Commissioner of Revenue Services
To ensure proper posting, write your SSN(s) (optional) and “2015 Form CT-1040NR/PY” on your check.

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