Form Ct-1040nr/py - Connecticut Nonresident And Part-Year Resident Income Tax Return - 2011 Page 2

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2011 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 2011 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 2012 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.
.
00
,
,
If you don’t elect direct deposit, the refund may be issued by debit card or check.
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.
Declaration: I declare under penalty of law that I have examined this return (including any accompanying
6
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
(
)
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.
Designee’s name
Telephone number
Personal identifi cation number (PIN)
Complete applicable schedules on Pages 3 and 4 and attach the schedules to your return.

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