Domicile Statement
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3Vermont Department of Taxes
133 State Street
Montpelier, VT 05633-1401
For Department Use Only
DOMICILE STATEMENT
For the taxable year ending ____________________
Unless otherwise indicated, the questions pertain to the the year specified above.
Your Name
Social Security Number
Spouse / CU Partner Name
Spouse / CU Partner Social Security Number
VERMONT Address
Other Address
City, State, ZIP Code
City, State, ZIP Code
1. Have you ever resided in Vermont with the intention of making it your home?
Yes When did you take up residency in Vermont? _________________________________________________
No
Please explain your connections with the State of Vermont. ______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. If you once resided in Vermont, did you leave not intending to return and did you take up residence in another state
with the intention of making that state your home?
Never resided in Vermont. Go to Question 3.
No. Go to Question 3.
Yes. 2a. Date you moved from Vermont _________________________________________________________
2b. Address to which you moved __________________________________________________________
2c. Date on which you took up residence in the new state _______________________________________
2d. What specific steps did you take to abandon your legal residence in Vermont? ___________________
__________________________________________________________________________________
__________________________________________________________________________________
2e. What specific steps did you take to establish your new legal residence? _________________________
__________________________________________________________________________________
__________________________________________________________________________________
3. Did you reside in two or more homes during the year?
No. Go to Question 4.
Yes Please state the address and dates on which you were physically present in each location:
Address
Periods (Dates)
Total number of days
________________________________________________
___________________
__________________
________________________________________________
___________________
__________________
________________________________________________
___________________
__________________
Rev. 2/07
Domicile Statement (Page 1 of 3)
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