State Of Connecticut Domicile Declaration {C-3}

Department of Revenue Services Estate Tax Section PO Box 2972 Hartford CT 06104-2972 (Rev. 05/11) Decedent's last name Form C-3 UGE State of Connecticut Domicile Declaration To be used by estates of decedents dying on or after January 1, 2005 First name and middle initial Age at death ZIP code Year domicile established Social Security Number (SSN) · · · · __ __ __ · __ __ · __ __ __ · · Date of death Connecticut Probate Court Decedent's residence on date of death (number and street, apartment number) City, town, or post office State General Instructions: Generally, whenever a decedent is claimed to be a nonresident of Connecticut, the fiduciary of the decedent's estate must file Form C-3 UGE, State of Connecticut Domicile Declaration. All questions must be answered fully for the declaration to be considered complete. For the estate of a decedent dying on or after January 1, 2005, Form C-3 UGE must be filed with the Department of Revenue Services (DRS) if the decedent's Connecticut taxable estate as valued for federal estate tax purposes exceeds the Connecticut estate tax exemption amount for the year of death and must be filed with the appropriate Connecticut Probate Court if the decedent's Connecticut taxable estate is equal to or less than the Connecticut estate tax exemption amount for the year of death. Complete this form in blue or black ink only. Attach additional statements as needed. 1. What is your relationship to the decedent? _______________________________________________________________________ 2. Did the decedent ever live in Connecticut? Yes No If Yes, list periods: ______________________________________ 3. Did the decedent live part of the year in Connecticut and part of the year outside of Connecticut? Yes No If Yes, list periods: __________________________________________________________________________________________ 4. Identify and list the address of each piece of real estate owned by the decedent, the decedent's spouse, or both, or a trust for the five years preceding death. Indicate whether the decedent lived in a house that was rented or owned, apartment, condominium, cooperative, hotel, nursing home, or in the home of relatives or friends. State the assessed and fair market value of real estate owned by the decedent, the decedent's spouse, or both, or a trust in the year of death. Date (From - To) Address/Town State Owned or Rented Description Assessed Value Fair Market Value Part Year Full Year 5. List the states where the decedent was registered to vote during each of the five years preceding death and attach copies of voter registration cards. List the latest year first. ______________________________________________________________________ 6. Identify in which state(s) or political subdivisions of state(s) the decedent filed income tax, property tax, or intangible tax returns and the taxes paid during the five years preceding death. Include the year(s) for which the returns were filed or tax paid. If an income tax return was filed, note whether it was a resident or nonresident return. Tax Year(s) State or Political Subdivision Tax Type Tax Paid Resident or Nonresident 7. Did the decedent file federal income tax returns? Yes No If Yes, what was the decedent's address on the returns? ___________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 8. Was the decedent employed or engaged in a business or profession in the five years preceding death? Yes No If Yes, list the employment or business activities engaged in by the decedent during the five years preceding the date of death. In Connecticut Period of Time (From - To) Period of Time (From - To) Outside Connecticut Nature of Employment or Business Activities Nature of Employment or Business Activities 9. Did the decedent execute a will, codicil, trust indenture, deed, mortgage, lease, or any other document in the five years preceding death? If Yes, give the dates and facts and attach copies of all documents. _______________________________ Yes No 10. Was the decedent a party to any legal proceedings in the State of Connecticut during the five years preceding death? Yes No If Yes, explain fully and submit copies of the court documents filed by or for the decedent. ______________ _______________________________________________________________________________________________________ 11. Did the decedent hold membership in any religious organizations, clubs, or societies in Connecticut in the five years preceding death? Yes No If Yes, detail the facts. ___________________________________________________________________ 12. Did the decedent hold membership in any religious organizations, clubs, or societies outside Connecticut in the five years preceding death? Yes No If Yes, detail the facts. ___________________________________________________________________ 13. Did the decedent lease a safe deposit box located in Connecticut at the time of death? If Yes, has it been inventoried? Yes No Yes NoIf Yes, attach copy of inventory. Name and address of bank where box is located: ________________________________________________________________ _______________________________________________________________________________________________________ 14. Did the decedent have a license in Connecticut or elsewhere to operate a business, profession, motor vehicle, airplane, or boat at any time within five years preceding death? License Number Type of License Date of Issuance Yes No If Yes, list below and attach copies of the license(s). Name and Location of Issuing Office 15. Was an automobile registered in the decedent's name in Connecticut or elsewhere at any time within five years preceding death? Yes No If Yes, where and when (that is, the dates of registrations)? ______________________________________ 16. Was the decedent hospitalized in Connecticut at any time within five years preceding death? Yes No If Yes, furnish name and address of the hospital(s) and the dates of hospitalization(s). ___________________________________ 17. Did the decedent undergo medical treatment or examination in Connecticut at any time within the five years preceding death? Yes No If Yes, furnish name and address of the doctor or hospital and the dates of treatment(s) or examination(s). _______________________________________________________________________________________________________ 18. Provide the place of the decedent's death and burial. Attach copies of the decedent's death certific