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Department of Revenue Services

Form CT-12-717A

Social Security Number

State of Connecticut

Change of Resident Status - Special Accruals

450 Columbus Blvd Ste 1

Hartford CT 06103-1837

Spouse’s Social Security Number

Connecticut Surety Bond Form

(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 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.

Know all persons by these presents, that I (we)

_________________________________________________________________________

_________________________________________________________________________________________________________________________

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 ofﬁ ce and usual place of business at

_________________________________________________

Connecticut,

_______________________________________________________________________________________________________________

as Surety, are held and ﬁ rmly 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, ﬁ rmly 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

(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 ﬁ le 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 ﬁ le 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 ﬁ le 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

day of

__________

________________

in the year of

______________

(Signed)

________________________________________________________________

Principal

Note: Add acknowledgments

________________________________________________________________

by both principal and surety,

Principal (Spouse)

ﬁ nancial statement of surety, etc.

________________________________________________________________

Surety

By (Signed)

________________________________________________________________

Attorney-in-fact

Form Ct-12-717a - Change Of Resident Status - Special Accruals Connecticut Surety Bond Form

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