Form Ct-1040nr/py - Connecticut Nonresident And Part-Year Resident Income Tax Return - 2012 Page 4

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2012 Form CT-1040NR/PY - Page 4 of 4
Your Social
-
-
Security Number
Schedule 3 - Individual Use Tax - Do you owe use tax?
See instructions, Page 37.
Complete the Connecticut Individual Use Tax Worksheet on Page 38 to calculate your use tax liability.
62a. Total use tax due at 1%: From Connecticut Individual Use Tax Worksheet, Section A, Column 7.
62a.
.
00
,
.
00
62b. Total use tax due at 6.35%: From Connecticut Individual Use Tax Worksheet, Section B, Column 7 62b.
,
00
.
62c. Total use tax due at 7%: 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, enter “0.”
00
Enter here and on Line 17.
62.
.
,
Schedule 4 - Contributions to Designated Charities
- See more information on Page 4.
.
00
63a. AIDS Research
63a.
,
,
.
00
63b. Organ Transplant
63b.
,
,
00
.
63c. Endangered Species/Wildlife
63c.
,
,
.
00
63d. Breast Cancer Research
63d.
,
,
.
00
63e. Safety Net Services
63e.
,
,
00
.
63f. Military Family Relief Fund
63f.
,
,
.
00
63.
Total contributions: Add Lines 63a through 63f, enter amount here and on Line 26.
63.
,
,
If any amounts are entered on Page 3 or 4, attach sheets to Pages 1 and 2, and send all four pages of the return to DRS.
Use the correct mailing address for returns requesting a refund or with a payment.
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 “2012 Form CT-1040NR/PY” on your check.

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