Connecticut Change of Resident Status - Special Accruals Other Acceptable Security Form

Change of Resident Status - Special Accruals Other Acceptable Security Form
CT-12-717B,  Change of Resident Status - Sepcial Accruals Other Acceptable Security Form
Department of Revenue Services
State of Connecticut
450 Columbus Blvd Ste 1
Hartford CT 06103-1837

Form CT-12-717B
Change of Resident Status - Special Accruals
Other Acceptable Security Form

(Rev. 03/17)

Social Security Number
Spouse’s Social Security Number

Complete this agreement and forward it by registered mail with the security described below to: Department of Revenue Services,
Attention: Director, Operations Division, 450 Columbus Blvd Ste 1, 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.
Whereas, I (we),

________________________________________________________________________________________________

(address as shown on return)

, of

_____________________________________________________________________________________________

,

have changed my (our) resident status for Connecticut income tax purposes from that of a resident individual(s) to that of a
nonresident individual(s) on (date) ____________ , and
Whereas, I (we) elect under Conn. Gen. Stat. §12-717(c)(4) to file my (our) Connecticut income tax return for the period
prior to my (our) change of residence on the cash receipts basis, and
Whereas, the tax as determined under Conn. Gen. Stat. §§12-700(c)(2) and 12-717(c)(1) for the portion of the taxable
year prior to my (our) change of residence would have been increased by the amount of $ _________________ if such election
had not been made, and
Whereas, I (we) hereby deposit with you the following described security:

I.

Bank passbooks and certificates of deposit:
Bank/Financial Institution

Amount

Maturity Date
(If certificate of deposit)

Attached and made part of this agreement is a letter prepared on the letterhead of the bank/financial institution and signed
by an officer thereof:
1.

Identifying the passbooks or certificates of deposit by account number and confirming that withdrawal of principal from
the passbook or certificate of deposit will not be permitted without written consent from the Connecticut Department of
Revenue Services (DRS); and

2.

Stating that any right of setoff which the bank/financial institution may possess against the taxpayer(s) resulting from
a defaulted obligation of the taxpayer(s) shall be subordinate to the interest of DRS in the passbook or certificate of
deposit offered as collateral.

II. Standby letter of credit:
Issuer or Confirming Bank

Amount

Expiration Date

Attached and made part of this agreement is the irrevocable standby letter of credit made payable to DRS.

III. Form W-2G, Certain Gambling Winnings:
Attached and made part of this agreement is a copy of the completed federal Form W-2G, Certain Gambling Winnings,
showing Connecticut income tax was withheld from my (our) Connecticut lottery payments.
Now, therefore, I (we) agree that (1) I (we) will include in my (our) Connecticut income tax returns in subsequent taxable years
(or periods) all income and gain accrued prior to my (our) change of residence as if I (we) had not changed my (our) resident
status and will pay the tax thereon when due; (2) the period of limitation within which tax may be assessed, set forth in Conn.
Gen. Stat. §12-733, is hereby extended as provided by subsection (f) of such section, and I (we) hereby agree that the tax
due may be assessed for any taxable year (or periods) at any time within three years after the tax return relating to the last
taxable year during which income or gain accruing prior to my (our) change of residence is actually received has been filed;
and (3) if the DRS determines (a) that I (we) have failed to include in my (our) Connecticut income tax return for any taxable
year (or period) any item of income or gain required to be included therein under the terms of this agreement or to pay any
tax required to be paid, or (b) that the security filed herewith has or will become inadequate to properly secure payment of
the tax, the full amount of income which is accruable under Conn. Gen. Stat. §12-717(c)(1) shall be accrued to the portion
of the taxable year prior to the change of residence and the additional tax for the period, as recomputed, shall become due
immediately. If the tax is not paid within 30 days after notice of a determination described in (a) above has been mailed to
me (us) by ordinary mail, or if the security which has been determined, as described in (b) above, to be inadequate to secure
payment of the tax is not replaced with adequate security acceptable to DRS within 30 days after notice of a determination
has been mailed to me (us) by ordinary mail, DRS may sell, assign, transfer, withdraw, or otherwise dispose of said security
and apply the proceeds to any unpaid portion of the tax deferred by reason of the election and any interest and penalties
due thereon. The balance of such proceeds, if any, shall be paid to me (us).
The security described above is deposited with the understanding that: (1) in case no disposition is made thereof
under the terms of this agreement, such security will be returned to me (us) at such time as DRS determines it is no
longer needed as security by reason of the full or partial payment of the tax deferred as a result of the election under
Conn. Gen. Stat. §12-717(c)(4); and (2) any interest accruing on said security shall belong to me (us).
Signature of taxpayer

Spouse’s signature (If joint return)

Form CT-12-717B Back (Rev. 03/17)

Date