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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

Date

Spouse’s signature (If joint return)

Form CT-12-717B Back (Rev. 12/06)

Form Ct-12-717b - Change Of Resident Status - Special Accruals Other Acceptable Security Form Page 2