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Department of Revenue Services
State of Connecticut Form CT-EITC SEQ 2022
(Rev. 12/22) Earned Income Tax Credit Self-Employed Questionnaire
Complete in blue or black ink only. If requested, mail completed Form CT-EITC SEQ and all documents to:
Form CT-EITC SEQ is only to be completed and submitted upon Department of Revenue Services
request by the DRS. Do not file Form CT-EITC SEQ with your tax State of Connecticut
return. Keep a copy of the completed form for your records. PO Box 2980
Hartford, CT 06104-2980
Enter all applicable information in Sections 1, 2, and 3 and attach copies
of all required documents.
Section 1 - Taxpayer Information
Your first name and middle initial Last name Your Social Security Number
• ••
__ __ __ __••• __ __•• __ __ __
If joint return, spouse’s first name and middle initial Last name Spouse’s Social Security Number
• ••
Taxpayer __ __ __ __••• __ __•• __ __ __
__ __ __ __ __ __ __ __ __
Information Name of business Employer Identification••••Number
Please type Business mailing address (number and street, apartment number, suite number, PO Box) Home telephone number
or print.
– –
City, town, or post office State ZIP code Business telephone number
– –
Business website (if any) Cell telephone number
– –
Section 2 - Business Information: (Federal Schedule K-1s, Schedule C, etc.)
Provide a description of your business (type of work, products sold, services provided, and hours of operation): ____________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
1. Date business began: ______________ / ____ / _______ Date business began in Connecticut: ______________ / ____ / _______
2. Have you received any Forms 1099-MISC or 1099-NEC for income you earned in 2022?
No Yes If Yes, attach a copy of each 1099-MISC or 1099-NEC.
3. If your occupation requires you to have a license, attach a copy of that license.
4. Indicate if you use any of the following methods to advertise your business. Attach copies of advertisements along with any paid
receipts.
Newspaper Internet/website Flyers Other ______________________________________
5. Under Connecticut Law, you must keep adequate business records. See Informational Publication 2015(20), Connecticut Earned
Income Tax Credit Recordkeeping Requirements for Self-employed Persons. Indicate which of the following types of records you
keep to verify your business income and expenses.
Accounting records Computer records Insurance Business bank account(s) Ledgers
Rental expenses Car/truck expenses Log books Suppliers (name and address)
Paid invoices/receipts Other ________________________________________________________________________
Attach copies of these records covering at least two months of the tax year in question.
Section 3 - Declaration and Signature
Declaration: I declare under penalty of law that I have examined the information contained on this questionnaire 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 the Department of Revenue Services
(DRS) is a fine of not more than $5,000 or imprisonment for not more than five 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
Sign
Spouse’s signature Date
Here
Keep a Paid preparer’s signature Date Telephone Preparer’s PTIN
copy – –
for your Firm’s name, address, and ZIP code FEIN
records.
Visit us at portal.ct.gov/DRS for more information.