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State Of Connecticut Domicile Declaration Form. This is a Connecticut form and can be use in Department Of Revenue Services Statewide.
Tags: State Of Connecticut Domicile Declaration, C-3, Connecticut Statewide, Department Of Revenue Services
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?____________________________________________________________
_
_
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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)
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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
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