Form Ct-941 - Connecticut Quarterly Reconciliation Of Withholding - 2012
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1Department of Revenue Services
2012
Form CT-941
PO Box 2931
Hartford CT 06104-2931
Connecticut Quarterly Reconciliation of Withholding
CT-941 (Rev. 12/11)
Complete this return in blue or black ink only.
General Instructions
Payers of nonpayroll amounts must use Form CT-945, Connecticut
Annual Reconciliation of Withholding for Nonpayroll Amounts.
Form CT-941 may be used by new employers or employers who have
not received their 2012 Connecticut Employer Wage Withholding Returns
See instructions on back. Sign and date the return in the space provided.
and Instructions. Form CT-941 (DRS) is used to reconcile quarterly
If payment is due, remit payment with this return.
Connecticut income tax withholding from wages only.
Connecticut Tax Registration Number
Name
Taxpayer
Number and street
PO Box
Federal Employer ID Number (FEIN)
Please
type
City or town
State
ZIP code
or print.
Enter reporting quarter (1, 2, 3, or 4)
If you no longer have employees in Connecticut, check here:
Due date
/
/
Enter date of last payroll:
M M
D D
Y Y Y Y
Section 1
1. Gross wages ..........................................................................................................................
1
00
2. Gross Connecticut wages ......................................................................................................
2
00
3. Connecticut tax withheld ....................................................................................................
3
00
4. Credit from prior quarter .......................................................................................................
4
00
5. Payments made for this quarter.............................................................................................
5
00
6. Total payments: Add Line 4 and Line 5. ................................................................................
6
00
7. Net tax due (or credit): Subtract Line 6 from Line 3. .............................................................
7
00
8a. Penalty: .........................................................................
8a
00
8b. Interest: .........................................................................
8b
00
8 Total penalty and interest: Add Line 8a and Line 8b. ...............................................................
8
00
9. Amount to be credited ...........................................................................................................
9
00
10. Amount to be refunded .........................................................................................................
10
00
For faster refund, use Direct Deposit by completing Lines 10a, 10b, and 10c.
10a. Checking
Savings
10b. Routing number
10c. Account number
10d. Will this refund go to a bank account outside the U.S.?
Yes
11
11. Total amount due: Add Line 7 and Line 8. ..........................................................................
00
Section 2 - Summary of Connecticut Tax Liability for the Calendar Quarter: See Instructions on back.
Pay
A
B
C
First Month
Second Month
Third Month
Period
1.
2.
3.
4.
5.
6.
7. Totals
8. Total liability for the quarter: Add Line 7, Columns A, B, and C. Enter total.
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.
Signature
Date
Title
Telephone number
(
)
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