Department of Revenue Services Estate Tax Section PO Box 2972 Hartford CT 06104-2972 (Rev. 9/08) Form C-3 State of Connecticut Domicile Declaration Decedent’s Last Name First Name and Middle Initial Decedent’s Residence on Date of Death (Number and Street) City, Town, or Post Office State Age at Death Social Security Number • • __ __ __ • __ __ • __ __ __ • • • • Date of Death ZIP Code Year Domicile Established Connecticut Probate Court General Instructions: Generally, whenever a decedent is claimed to be a nonresident of Connecticut, the fiduciary of the decedent’s estate must file Form C-3, State of Connecticut Domicile Declaration. All questions must be answered fully in order for the declaration to be considered complete. Form C-3 must be filed with the Department of Revenue Services (DRS) if the decedent’s Connecticut taxable estate is over $2 million, and must be filed with the appropriate Connecticut Probate Court if the decedent’s Connecticut taxable estate is $2 million or less as valued for federal estate tax purposes. Attach additional statements as needed. 1. What is your relationship to the decedent?________________________________________________________________________ 2. Did the decedent ever live in Connecticut?   Yes No If Yes, list periods:_ ______________________________________ 3. Did the decedent live part of the year in Connecticut and part of the year outside of Connecticut?  Yes  No If Yes, list periods:_ _________________________________________________________________________________________ _ 4. Identify and list the address of each and every piece of real estate owned by the decedent or the decedent’s spouse, or both, or a trust for the five years preceding death. Indicate whether the decedent lived in a house that was rented or owned, apartment, condominium, hotel, nursing home, or in the home of relatives or friends. State the assessed and fair market value of real estate owned by the decedent or the decedent’s spouse, or both, or a trust in the year of death. Date (From - To) Address/Town State Owned or Rented Description Assessed Value Fair Market Value Part Year Full Year 5. List the states where the decedent was registered to vote during each of the five years preceding death and attach copies of voter registration cards. List the latest year first. _______________________________________________________________________ 6. Identify in which state(s) or political subdivisions of state(s) the decedent filed income tax, property tax, or intangible tax returns, and the taxes paid during the five years preceding death. Include the year(s) for which the returns were filed or tax paid. If an income tax return was filed, note whether it was a resident or nonresident return. Tax Year(s) State or Political Subdivision Tax Type 7. Did the decedent file federal income tax returns?  Yes  Tax Paid Resident or Nonresident No If Yes, what was the decedent’s address on the returns?____________________________________________________________ _ _ Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 8. Was the decedent employed or engaged in a business or profession in the five years preceding death?  Yes  No If Yes, list the employment or business activities engaged in by the decedent during the five years preceding the date of death. In Connecticut Period of Time (From - To) Outside Connecticut Period of Time (From - To) Nature of Employment or Business Activities Nature of Employment or Business Activities 9. Did the decedent execute a will, codicil, trust indenture, deed, mortgage, lease, or any other document in the five years preceding death?  Yes  No If Yes, give dates and facts and attach copies of all documents.____________________________________ 10. Was the decedent a party to any legal proceedings in the State of Connecticut during the last five years preceding death?  _ _______________________________________________________________________________________________________ Yes  No If Yes, explain fully and submit copies of the court documents filed by or for the decedent.________________ 11. Did the decedent hold membership in any religious organizations, clubs, or societies in Connecticut in the five years preceding death?  Yes  No If Yes, detail the facts:_ ____________________________________________________________________ 12. Did the decedent hold membership in any religious organizations, clubs, or societies outside Connecticut in the five years preceding death?  Yes  No If Yes, detail the facts:_ ____________________________________________________________________ 13. Did the decedent lease a safe deposit box located in Connecticut at the time of death? If Yes, has it been inventoried?   No Yes  Yes  No If Yes, attach copy of inventory. Name and address of bank where box is located:_ ________________________________________________________________ _ _______________________________________________________________________________________________________ 14. Did the decedent have a license in Connecticut or elsewhere to operate a business, profession, motor vehicle, airplane, or boat at any time within five years preceding death? License Number Type of License  Yes  Date of Issuance No If Yes, list below and attach copies of the license(s). Name and Location of Issuing Office 15. Was an automobile registered in the decedent’s name in Connecticut or elsewhere at any time within five years preceding death?  Yes  No If Yes, where and when (that is, the dates of registrations):_ _________________________________________ _ 16. Was the decedent hospitalized in Connecticut at any time within five years preceding death?  Yes  No If Yes, furnish name and address of the hospital(s) and the dates of hospitalization(s)._ ___________________________________ 17. Did the decedent undergo medical treatment or examination in Connecticut at any time within the five years preceding death?  _ _______________________________________________________________________________________________________ Yes  No If Yes, furnish name and address of the doctor or hospital and the dates of treatment(s) or examination(s). 18. Provide the place of the decedent’s death and burial. Attach copies of the decedent’s death certificate and obituaries in the newspapers in Connecticut and elsewhere._ _______________________________________________________________________________ Form C-3 (Rev. 9/08) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 19. Name and address of the bank to which decedent’s Social Security payments were deposited during each of the five years preceding death._ __________________________________________________________________________________________________ _ _______________________________________________________________________________________________________ _ _______________________________________________________________________________________________________ 20. Did the decedent execute and file a Declaration of Domicile in another jurisdiction?  Yes  No If Yes, attach a copy. 21. If the decedent was at one time a resident of Connecticut, what event(s) or action(s) changed the decedent’s status to nonresident? _ ________________________________________________________ On what date did this occur? _______________________ 22. What additional information do you wish to submit in support of the contention that the decedent was not domiciled in Connecticut at the time of death? Attach additional sheets, if necessary. ___________________________________________________________ _ _______________________________________________________________________________________________________ 23. Enter the number of days the decedent actually stayed in Connecticut and in the state where domicile is claimed for each of the five years preceding death. The estate may be asked to provide more details to support the information provided. Year Days in Connecticut Days in State Where Decedent’s Domicile Is Claimed 24. List the name, address, and relationship of all family members of the decedent with whom he or she had the closest familial relationship. Name Address Relationship 25. Give an estimation of the total value of the Connecticut taxable estate, wherever located. This amount includes Connecticut taxable gifts made by the decedent during all calendar years beginning on or after January 1, 2005: $_____________________________ 26. Signature and Declaration Attorney or Authorized Representative’s Name Telephone Number ( ) Law Firm Name Address City State ZIP Code Declaration: I declare under penalty of law that I have examined this document (including any accompanying 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 document to 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. Telephone Number Sign Here Fiduciary’s Name Keep a copy of this return for your records. ( Address City State ) ZIP Code Fiduciary’s Signature Official Determination Use Only Form C-3 (Rev. 9/08) Signed  Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com