Domicile Declaration - Connecticut
Form C-3 UGE
State of Connecticut Domicile Declaration
Department of Revenue Services
Estate Tax Section
PO Box 2972
Hartford CT 06104-2972
(Rev. 05/11)
Decedent’s last name First name and middle initial Social Security Number (SSN)
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Decedent’s residence on date of death (number and street, apartment number) Age at death Date of death
City, town, or post offi ce State ZIP code Connecticut Probate Court
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General Instructions: Generally , whenever a decedent is claimed to be a nonresident of Connecticut, the fi duciary of the decedent’s estate
must fi le 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 fi led 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 fi led 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
fi ve 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.
5. List the states where the decedent was registered to vote during each of the fi ve years preceding death and attach copies of voter
registration cards. List the latest year fi rst. ______________________________________________________________________
6. Identify in which state(s) or political subdivisions of state(s) the decedent fi led income tax, property tax, or intangible tax returns and
the taxes paid during the fi ve years preceding death. Include the year(s) for which the returns were fi led or tax paid. If an income tax
return was fi led, note whether it was a resident or nonresident return.
7. Did the decedent fi le federal income tax returns? Yes No
If Yes, what was the decedent’s address on the returns? ___________________________________________________________
Date Owned Assessed Fair Market Part Full
(From - To) Address/Town State or Rented Description Value Value Year Year
Tax Year(s) State or Political Subdivision Tax Type Tax Paid Resident or Nonresident
Year domicile
established
To be used by estates of decedents dying on or after January 1, 2005
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