Connecticut Title 19 Status Release Form

Title 19 Status Release Form
Form CT-19 IT
Department of Revenue Services
State of Connecticut

2023

Form CT-19IT

(Rev. 12/23)

Title 19 Status Release

Please note that each form is year specific. To prevent any delay in processing your return, the correct year’s form must be
submitted to the Department of Revenue Services (DRS).
Your first name and middle initial	

Last name	

	

Social Security Number
•

•

­­__ __ __ ••• __ __ ••• __ __ __ __
Mailing address (number and street), apartment number, PO Box	

		 Telephone

–	–

		
State		

City, town, or post office		

ZIP code

Purpose
Use Form CT‑19IT to claim your Title 19 status. You
must include a copy of the Department of Social
Services (DSS) acceptance or redetermination letter
for the 2023 taxable year.
Electronic filers: If you are filing electronically, select
the indicator for Form CT-19IT on your Connecticut
income tax return. Complete Form CT-19IT and upload
as an attachment.
Paper filers: Check the box for Form CT-19IT on the
front of your Connecticut income tax return. Place this
form on top of the completed Connecticut income tax
return. Complete in blue or black ink only.

Who May Not File Form CT‑19IT

Who May File Form CT‑19IT
If you are required to file a Connecticut income tax
return, you may file Form CT‑19IT if you meet all the
following conditions:
1.	 You were a Title 19 recipient during the taxable year;
2.	 Medicaid assisted in the payment of your long‑term
care in a nursing or convalescent home or under the
Connecticut Home Care Program for Elders (CHCPE);
and
3.	 You do not have the funds to pay your Connecticut
income tax or income available from future earnings
to pay the tax.

3.	 You made estimated tax payments to Connecticut
or made a payment with Form CT‑1040 EXT,
Application for Extension of Time to File Connecticut
Income Tax Return for Individuals; or

You may not use this form if you filed a joint return with
your spouse. As joint filers, you are jointly and severally
liable for payment of the tax. If one spouse is on Title 19,
this does not relieve the other spouse from paying the
full amount of tax due.
General Information
You are required to file a Connecticut income tax return
if you meet any of the following conditions:
1.	 You meet the gross income test (See the instructions
for Form CT‑1040 or Form CT‑1040NR/PY.);
2.	 You had Connecticut income taxes withheld;

4.	 You had a federal alternative minimum tax liability.
Complete Form CT‑19IT and place it on top of your
completed Connecticut income tax return.

If the recipient has given power of attorney to another person to file Connecticut income tax returns or other
Connecticut tax forms on the recipient’s behalf, attach a copy of the Power of Attorney.
Signature of recipient 	

Date

Signature of person with power of attorney	

Date

Name of person with power of attorney (print or type)	

Telephone number
–	–

Visit us at portal.ct.gov/DRS for more information.