Form 3799 - Statement To Determine State Of Domicile Page 2

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3799, Page 2

Yes

Did you file a tax return in another state? If yes, attach of a copy of the return.

PART 4: PHYSICALLY LOCATED IN YOUR NEW DOMICILE

If yes, will your spouse move to your new location?

Yes

No*

Are you married?

If yes, will they move to your new location?

Yes

No*

Do you have dependents?

*If you answered no to either of these questions, attach an explanation.

List the name(s) and location(s) (city, state) of institutions where you have savings and checking accounts or safe deposit boxs. Attach additional sheets if necessary.

List the name(s) and location(s) (city, state) of any organizations that you belong to.

PART 5: STATEMENT TO DETERMINE STATE OF DOMICILE

Check one that applies.

My domicile is no longer in Michigan as of (date) ________________________. On this date, I had the specific intent to abandon my

Michigan domicile. I had the specific intent to acquire my new domicile outside Michigan, and I was actually physically present in my new

domicile. I understand that I must file a Michigan income tax return as a part-year resident for the year of change.

My domicile continues to be in Michigan. I understand that I must continue filing Michigan income tax returns as a resident.

Signature

Date