Form Ct-19it - Title 19 Status Release Form - State Of Connecticut - 1998
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1TITLE 19 STATUS RELEASE FORM
Who may file Form CT-19IT?
General Instructions
If you are a Title 19 recipient, you are required to file a Connecticut
If you meet the conditions listed below, you may file Form CT-19IT,
income tax return if you meet any of the following conditions:
Title 19 Status Release Form, to give permission to the Department of
Revenue Services to verify your Title 19 status for the taxable year with
1. You had Connecticut income taxes withheld; or
the Department of Social Services:
2. You made estimated tax payments to Connecticut; or
1. You were a Title 19 recipient during the taxable year; and
3. You meet the Gross Income Test (See instructions for
2. Medicaid assisted in the payment of your long-term
Form CT-1040 or Form CT-1040EZ); or
care in a nursing or convalescent home or under the
Connecticut Home Care for Elders; and
4. You had a federal alternative minimum tax liability.
3. You do not have the funds to pay your Connecticut
Complete Form CT-19IT and attach it to the front of your Connecticut
income tax, or income available from future
income tax return. By completing this form you authorize the Department of
earnings to pay the tax.
Revenue Services to verify your Title 19 status for 1998 with the
Department of Social Services.
First Name
Last Name
Social Security Number
Middle Initial
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•
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__ __ __ __ __ __ __ __ __
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Telephone
Number and Street
(
)
ZIP Code
State
City, Town or Post Office
Taxable year for which I am claiming Title 19 status:
If the recipient has given power of attorney to another person to file Connecticut income tax returns or other Connecticut tax forms on
behalf of the recipient, attach a copy of the Power of Attorney form.
Signature of Recipient Named Above
Date
Signature of Person with Power of Attorney
Date
Name of Person with Power of Attorney (Print or Type)
Form CT-19IT (Rev. 12/98)
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