Form Ct-1040nr/py - Connecticut Nonresident And Part-Year Resident Income Tax Return - 2012 Page 2

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2012 Form CT-1040NR/PY - Page 2 of 4
Your Social
-
-
Security Number
.
00
19. Enter amount from Line 18.
19.
,
,
Column C
Column A
Column B
3
Employer’s federal ID No. from Box b of W-2 or
Connecticut wages, tips,
Connecticut income tax withheld
Schedule
Check box at left if from Schedule CT K-1.
payer’s federal ID No. from Schedule CT K-1 or 1099
etc.
CT K-1
.
–
00
20a.
00
20a.
.
,
,
W-2
and 1099
.
–
00
20b.
20b.
.
,
,
00
Information
.
Only enter
–
00
20c.
.
00
20c.
,
,
information
from your W-2,
.
–
00
20d.
.
20d.
00
,
,
Schedule
CT K-1, and
.
–
00
20e.
20e.
.
00
,
,
1099 forms if
Connecticut
.
–
00
20f.
.
20f.
00
income tax
,
,
was withheld.
.
–
00
20g.
.
20g.
00
,
,
Additional CT withholding from Supplemental Schedule CT-1040WH.
20h.
20h.
.
00
,
,
20. Total Connecticut income tax withheld: Add amounts in Column C and enter here.
.
00
,
,
You must complete Columns A, B, and C or your withholding will be disallowed.
20.
.
21. All 2012 estimated tax payments and any overpayments applied from a prior year
21.
00
,
,
.
00
22. Payments made with Form CT-1040 EXT (Request for extension of time to fi le)
22.
,
,
.
00
23. Total payments: Add Lines 20, 21, and 22.
23.
,
,
.
4
00
24. Overpayment: If Line 23 is more than Line 19, subtract Line 19 from Line 23.
24.
,
,
.
00
25. Amount of Line 24 overpayment you want applied to your 2013 estimated tax
25.
,
,
26. Total contributions of refund to designated charities from Schedule 4, Line 63
26.
.
00
,
,
27. Refund: Subtract Lines 25 and 26 from Line 24. For faster refund, use direct
deposit by completing Lines 27a, 27b, and 27c. If you don’t elect direct deposit,
.
00
,
,
in most cases, the refund will be issued by debit card.
27.
27a. Checking
27b. Routing
27c. Account
Savings
number
number
27d. Will this refund go to a bank account outside the U.S.?
Yes
5
.
00
28. Tax due: If Line 19 is more than Line 23, subtract Line 23 from Line 19.
28.
,
,
.
00
,
,
29. If late: Enter penalty. Multiply Line 28 by 10% (.10).
29.
30. If late: Enter interest. Multiply Line 28 by number of months or fraction of a month
.
00
,
,
late, then by 1% (.01).
30.
.
00
,
,
31. Interest on underpayment of estimated tax: See instructions, Page 19.
31.
.
00
,
,
32. Total amount due: Add Lines 28 through 31.
32.
6
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and
statements) 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 DRS is a fi ne of not more than $5,000, or 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
Daytime telephone number
(
)
Your email address
Spouse’s signature (if joint return)
Date
Daytime telephone number
(
)
Paid preparer’s signature
Date
Telephone number
Preparer’s SSN or PTIN
(
)
Firm’s name, address, and ZIP code
FEIN
Third Party Designee - Complete the following to authorize DRS to contact another person about this return.
(PIN)
Designee’s name
Telephone number
Personal identifi cation number
Complete applicable schedules on Pages 3 and 4 and send all four pages of the return to DRS.

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