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19. Name and address of the bank to which decedent’s social security payments were deposited during each of the ﬁ ve years preceding

death. __________________________________________________________________________________________________

_______________________________________________________________________________________________________





20. Did the decedent execute and ﬁ le a Declaration of Domicile in another jurisdiction?

Yes

If Yes, attach a copy.

21. If the decedent was at one time a resident of Connecticut, what event(s) or action(s) changed the decedent’s status to nonresident?

________________________________________________________ On what date did this occur? ______________________

22. What additional information do you wish to submit in support of the contention that the decedent was not domiciled in Connecticut at

the time of death? Attach additional sheets if necessary. ___________________________________________________________

_______________________________________________________________________________________________________

23. Enter the number of days the decedent actually stayed in Connecticut and in the state where domicile is claimed for each of the ﬁ ve

years preceding death. The estate may be asked to provide more details to support the information provided.

Year

Days in Connecticut

Days in State Where Decedent’s Domicile Is Claimed

24. List the name, address, and relationship of all family members of the decedent with whom he or she had the closest familial relationship.

Name

Address

Relationship

25. Estimate the total value of the gross estate, less deductions, for federal estate tax purposes. Be sure to add to that ﬁ gure the Connecticut

taxable gifts made by the decedent during all calendar years beginning on or after January 1, 2005: $ ___________________________

26. Signature and declaration

Attorney or authorized representative’s name

Date

Telephone number

(

)

Law ﬁ rm name

Address

City

State

ZIP code

Declaration for DRS: I declare under penalty of law that I have examined this document (including any accompanying schedules and statements) and, to the

best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false document to DRS is a ﬁ ne of not more

than $5,000, imprisonment for not more than ﬁ ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which

the preparer has any knowledge.

Declaration for Probate Court: I declare under penalty of false statement under Conn. Gen. Stat. §§53a-157b that I have examined this document (including

any accompanying schedules and statements) and, to the best of my knowledge and belief, it is true, complete, and correct. The declaration of a paid preparer

other than the ﬁ duciary is based on all information of which the preparer has any knowledge

Fiduciary’s name

Telephone number

Sign Here

(

)

Keep a

Address

City

State

ZIP code

copy of