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Department of Revenue Services

Form CT-12-717A

Social Security Number

State of Connecticut

25 Sigourney Street

Change of Resident Status - Special Accruals

Hartford CT 06106-5032

Spouse’s Social Security Number

Connecticut Surety Bond Form

(Rev. 12/06)

Complete this agreement and forward it by registered mail to: Department of Revenue Services, Attention: Director, Operations

Division, 25 Sigourney Street, Hartford CT 06106-5032. If filing a joint return, include both names. Enter your Social Security

Number(s) above.

When filing 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) ___________________________________________________________

of _________________________________________________________________________________________________

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 office and usual place of business at _________________________________________

Connecticut,

as Surety, are held and firmly 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, firmly 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)

to _______________________________________________________________________________________ (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 file 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 file 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 file 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)

Note: Add acknowledgments by

Principal

both principal and surety,

___________________________________________________

financial statement of

Principal (Spouse)

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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