Form Ct-1na - Connecticut Nonresident Income Tax Agreement

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STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
FORM CT-1NA
(Rev. 12/00)
Connecticut Nonresident Income Tax Agreement
– Refer to Instructions Below –
Nonresident’s Taxable Year
Taxable Year of S Corporation
Beginning ______________, 2000, and Ending ______________, ______
Beginning ______________, 2000, and Ending ______________, ______
NONRESIDENT INDIVIDUAL’S NAME AND MAILING ADDRESS
S CORPORATION’S NAME AND MAILING ADDRESS
NAME
NAME
STREET OR OTHER MAILING ADDRESS
STREET OR OTHER MAILING ADDRESS
CITY OR TOWN
STATE
ZIP CODE
CITY OR TOWN
STATE
ZIP CODE
SOCIAL SECURITY NUMBER
SPOUSE’S SOCIAL SECURITY NUMBER
CONNECTICUT TAX REGISTRATION NUMBER FEDERAL EMPLOYER ID NUMBER
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Internal Revenue Service Center Where Nonresident Individual’s Federal Return is Filed ____________________________________________
INSTRUCTIONS
Who May File: Any nonresident individual who is a shareholder of an S corporation that has income derived from or connected with
sources within Connecticut may complete Form CT-1NA, Connecticut Nonresident Income Tax Agreement . If no Form CT-1NA is
attached to the S corporation’s return and the shareholder is not part of a group return, the S corporation is required to include the
nonresident’s income derived from, or connected with, sources within Connecticut in the computation of the composite return tax due on
Form CT-1120SI, S Corporation Information and Composite Income Tax Return. Nonresidents whose only connection with Connecticut
is as shareholders of an S corporation carrying on business in Connecticut, do not have to file Form CT-1040NR/PY, Connecticut
Nonresident or Part-year Resident Income Tax Return , if their income is included on Form CT-1120SI.
When and Where to File: Form CT-1NA must be completed and delivered to the S corporation prior to the filing of Form CT-1120SI
by the S corporation for each taxable year. The due date for Form CT-1120SI is the 15th day of the fourth month following the close of the
taxable year.
DECLARATION: I declare that I am or have been a nonresident of Connecticut, and hereby agree that I will timely file Form CT-1040NR/PY,
Connecticut Nonresident or Part-Year Resident Income Tax Return, make timely payment of any income tax due on such return with respect
to the income of the S corporation named above, and agree to be subject to personal jurisdiction in Connecticut for purposes of the collection
of said income tax, together with any additions to tax, interest, and penalties.
This agreement shall be binding upon my heirs, representatives, assigns, successors, executors, and administrators.
Sign Here __________________________________________________________________________________________________
Your Signature
Date
Spouse’s Signature (if joint return)
Date

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