Form 3799 - Statement To Determine State Of Domicile
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Michigan Department of Treasury
Form 3799 (Rev. 05-01)
Statement to Determine State of Domicile
This form is issued under authority of Michigan Administrative Rule 206.5. Filing of this form is voluntary. Without the necessary information, the Michigan Department of
Treasury will assume the individual was Michigan resident.
Instructions: Complete this form to clarify for the Michigan Department of Treasury your domicile for tax purposes. Michigan residents are subject to
income tax on all taxable income from any source (MCL 206.110). You are a Michigan resident if your domicile is in Michigan.
Your domicile is where you have your permanent home. It is the place you plan to return to whenever you go away. You may have several residences,
but you can have only one domicile at a time (MCL 206.18). That domicile continues until a new permanent home is established. Once established,
your domicile can only change when these three criteria are met:
1. you have a specific intent to abandon your old domicile,
2. you have a specific intent to acquire a new domicile, and
3. you are physically living in your new domicile.
You must show specific proof of each of these criteria, Please answer each item below and provide attachments where requested.
PART 1: GENERAL INFORMATION
Name (first, middle, last)
Social Security Number
What address did you file your last Michigan Income Tax Return from? (Number, Street, City, State, and ZIP Code)
What address did you file your last Federal Income Tax Return from? (Number, Street, City, State and ZIP Code)
PART 2: SPECIFIC INTENT TO ABANDON YOUR OLD DOMICILE
A. If you are employed, have you been
If yes, how long do you expect to be at
transferred?
your new location?
Permanent
Yes
No
Specify:
__________
Years
B. Have you ever held a Michigan driver’s
If yes, what is its expiration date?
license?
Yes
No
_____________________________________
If yes, where are you registered
Are you registered to vote?
Yes
No
(city and state)?
C.
_____________________________________
If yes, where will it be probated
Do you have a will?
Yes
No
(state)?
D.
_____________________________________
What is the year on your license
What state is your car registered in?
Yes
No
plate?
_____________________________________
E.
If yes, what do you intend to do with
F. Do you or your spouse own or rent a
this property?
home in Michigan?
Yes
No
_____________________________________
_____________________________________
PART 3: SPECIFIC INTENT TO ACQUIRE A NEW DOMICILE
What is your intended address outside Michigan? (Number, Street, City, State and ZIP Code)
.
A
Have you made a formal declaration of domicile in any other state? If yes, attach a copy of the declaration.
Yes
No
B.
Do you have a valid Driver’s license from another state? If yes, attach a copy.
Yes
No
C.
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