Connecticut Change of Resident Status - Special Accruals Connecticut Surety Bond Form

Change of Resident Status - Special Accruals Connecticut Surety Bond Form
CT-12-717A,  Change of Resident Status - Special Accruals Connecticut Surety Bond Form
Department of Revenue Services
State of Connecticut
450 Columbus Blvd Ste 1
Hartford CT 06103-1837

Form CT-12-717A
Change of Resident Status - Special Accruals
Connecticut Surety Bond Form

Social Security Number
Spouse’s Social Security Number

(Rev. 03/17)

Complete this agreement and forward it by registered mail to: Department of Revenue Services, Attention: Director, Operations
Division, 450 Columbus Blvd, Hartford CT 06103-1837. If filing a joint return, include both names. Enter your Social Security
Number(s) above.
When filing Form CT-1040NR/PY or Form CT-1041 for the taxable year in which the change of resident status occurred, attach
a copy of this form to the return.
Know all persons by these presents, that I (we)
of

_________________________________________________________________________

_________________________________________________________________________________________________________________________

as principal, and the

_______________________________________________________________________________________________________

a corporation organized under the laws of the State of ___________________________ and duly authorized to transact business
in the State of Connecticut, having an office and usual place of business at _________________________________________________
_______________________________________________________________________________________________________________

Connecticut,

as Surety, are held and firmly bound unto the People of the State of Connecticut and the Connecticut Department of Revenue
Services, the sum of ___________________________________________ lawful money of the United States of America, for the payment
whereof we bind ourselves, our successors, and assigns, jointly and severally, firmly by these presents.
Whereas, the principal on ___________________ (date) changed resident status, for purposes of the Connecticut income
tax administered by the Commissioner of Revenue Services,
from
to

________________________________________________________________________________________________________

(full address)

___________________________________________________________________________________________________________

(full address)

and is required under Conn. Gen. Stat. §§12-700(c)(2) and 12-717(c)(1) to determine Connecticut source income for the taxable
year ___________________ and under Conn. Gen. Stat §12-700 to file a return(s) as a part-year resident individual(s) for the
taxable
year ___________________ and
Whereas, due to such change of residence, certain additional amounts were includable under Conn. Gen. Stat.
§§12-700(c)(2) and 12-717(c)(1) in computing Connecticut adjusted gross income of the principal on the accrual basis for the
taxable period immediately prior to the change of residence, and
Whereas, the principal desires not to report on such principal’s return for the taxable period immediately prior to the change
of residence the amounts referred to in the preceding paragraph which would otherwise be includable under Conn. Gen. Stat.
§§12-700(c)(2) and 12-717(c)(1), and
Whereas, the principal elects to defer Connecticut income tax under Conn. Gen. Stat. §12-717(c)(4) and expressly agrees
to file the Connecticut nonresident income tax return or returns required by Conn. Gen. Stat. §12-717(c)(4) and to include thereon
the amounts so accruable under Conn. Gen. Stat. §12-717 in computing Connecticut adjusted gross income and Connecticut
source income and consents to personal jurisdiction in Connecticut for Connecticut income tax purposes, which election and
agreement shall be binding on the principal’s heirs, representatives, assigns, successors, executors, and administrators, and
Whereas, the tax for the taxable period prior to the change of residence would have been increased by the amount of
$

______________________________

if the election had not been made, and

Whereas, Conn. Gen. Stat. §12-717 requires a taxpayer to file a bond to secure future payments of tax calculated on the
amount of deferred income as if no change of residence occurred thereunder;
Now, therefore, the condition of this bond is such that if the principal shall pay the full amount of tax, and any penalties and
interest thereon, deferred for the taxable year _____________ by reason of the election under Conn. Gen. Stat. §12-717(c)(4) or
shall report for the applicable taxable years all items of income, gain, loss, or deduction which were accruable for the taxable
period immediately prior to such principal’s change of residence and which would otherwise have been required to be included
in the principal’s return for such period, then this obligation is to be void; otherwise, it shall be irrevocable and remain in full force
and effect. The obligations of the principal and surety under this bond may not be changed or terminated orally.
In witness whereof, said principal and surety have signed and sealed this instrument this
in the year of

______________ .

Note: Add acknowledgments
by both principal and surety,
financial statement of surety, etc.

__________

day of

________________

(Signed)
________________________________________________________________
Principal
________________________________________________________________
Principal (Spouse)
________________________________________________________________
Surety
By (Signed)
________________________________________________________________
Attorney-in-fact