Form C-3 - Domicile Declaration
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1
2State of Connecticut
FORM C-3
Department of Revenue Services
STATE OF CONNECTICUT
Inheritance/Estate Tax Section
DOMICILE DECLARATION
PO Box 2972
Hartford CT 06104-2972
Decedent’s Name (Last, First, Middle Initial)
Date of Death
Probate Court
Decedent’s Residence on Date of Death (Street Address)
Connecticut File Number, If Known
City
State
ZIP Code
Social Security Number
General Instructions: Generally, whenever a decedent is claimed to be a nonresident of Connecticut, the fiduciary of the
decedent’s estate must file a State of Connecticut Domicile Declaration. All questions must be answered fully to be considered a
complete declaration. If the Probate Court judge certifies that there is no succession tax due, and the estate is not required to file
federal Form 706, United States Estate (and Generation Skipping Transfer) Tax Return, the Domicile Declaration is only filed upon
request from the Department of Revenue Services. If you need more room to fully answer the questions below, please attach
additional statements as needed.
1. What is your relationship to the decedent?
2. Did the decedent ever live in Connecticut?
Yes
No
3. Did the decedent live part of the year in Connecticut and part of the year outside of Connecticut?
Yes
No
4. Identify and describe each place of residence of the decedent for the five years preceding death. Indicate whether the decedent
lived in a house that was rented or owned, apartment, condominium, hotel, nursing home, or in the home of relatives or
friends. State the assessed and fair market value of Connecticut real estate owned by the decedent for the year of death.
Date
Owned
Other
Assessed
Fair Market Part
Full
From - To
Town
State
or Rented
(please describe)
Value
Value
Year Year
5. Where, and in what years, did the decedent vote or register to vote during the five years preceding death?
6. Identify in which state(s) or political subdivisions of state(s) the decedent filed tax returns or paid tax on real or personal property
during the five years preceding death. Include the year(s) for which the returns were filed or tax was paid. If an income tax return
was filed, note whether it was a resident or nonresident return filed.
Tax Year(s)
State or Political Subdivision
Tax Type
Resident or Nonresident
7. Did the decedent file federal income tax returns?
Yes
No
If so, what was the decedent’s address on the returns?
Form C-3
(New3/99)
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