Form Ct-12-717b - Change Of Resident Status - Special Accruals Other Acceptable Security Form
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1
2Department of Revenue Services
Social Security Number
Form CT-12-717B
State of Connecticut
450 Columbus Blvd Ste 1
Change of Resident Status - Special Accruals
Hartford CT 06103-1837
Spouse’s Social Security Number
Other Acceptable Security Form
(Rev. 03/17)
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 fi ling a joint return, include both
names. Enter your Social Security Number(s) above.
When fi ling 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),
, of
________________________________________________________________________________________________
(address as shown on return)
,
_____________________________________________________________________________________________
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 fi le 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 certifi cates of deposit:
Maturity Date
Bank/Financial Institution
Amount
(If certifi cate of deposit)
Attached and made part of this agreement is a letter prepared on the letterhead of the bank/fi nancial institution and signed
by an offi cer thereof:
1.
Identifying the passbooks or certifi cates of deposit by account number and confi rming that withdrawal of principal from
the passbook or certifi cate 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/fi nancial 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 certifi cate of
deposit offered as collateral.
II. Standby letter of credit:
Issuer or Confi rming Bank
Amount
Expiration Date
Attached and made part of this agreement is the irrevocable standby letter of credit made payable to DRS.
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