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.