Form Ct-19it - Title 19 Status Release - 2014
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1Department of Revenue Services
2014
State of Connecticut
Form CT-19IT
25 Sigourney St Ste 2
Hartford CT 06106-5032
Title 19 Status Release
(Rev. 12/14)
Place this form on top of your completed Connecticut income tax return. Complete in blue or black ink only.
Your fi rst name and middle initial
Last name
Social Security Number
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Mailing address (number and street), apartment number, PO box
Telephone
(
)
City, town, or post offi ce
State
ZIP code
Purpose
Who May Not File Form CT-19IT
Use Form CT-19IT to authorize the Department of
You may not use this form if you fi led a joint return with
Revenue Services (DRS) to contact the Department
your spouse. As joint fi lers, you are jointly and severally
of Social Services to verify your Title 19 status for the
liable for payment of the tax. If one spouse is on Title
2014 taxable year.
19, this does not relieve the other spouse from paying
the full amount of tax due.
Who May File Form CT-19IT
General Information
If you are required to fi le a Connecticut income tax
return, you may fi le Form CT-19IT if you meet all the
You are required to fi le a Connecticut income tax return
following conditions:
if you meet any of the following conditions:
1. You were a Title 19 recipient during the taxable year;
1. You meet the gross income test (See the instructions
for Form CT-1040 or Form CT-1040NR/PY.);
2. Medicaid assisted in the payment of your long-term
care in a nursing or convalescent home or under the
2. You had Connecticut income taxes withheld;
Connecticut Home Care for Elders; and
3. You made estimated tax payments to Connecticut
3. You do not have the funds to pay your Connecticut
or made a payment with Form CT-1040 EXT,
income tax or income available from future earnings
Application for Extension of Time to File Connecticut
to pay the tax.
Income Tax Return for Individuals; or
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 fi le 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)
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