Vermont Department of Taxes     133 State Street     Montpelier, VT  05633-1401                        For Department Use Only
Phone:  (802) 828-2865

                  DOMICILE STATEMENT

                            For the taxable year ending ____________________
                  Unless otherwise indicated, the questions pertain to the year specified above.
   Your Name                                                                     Social Security Number

   Spouse / CU Partner Name                                                      Spouse / CU Partner Social Security Number

   VERMONT Address                                          Other Address

   City, State, ZIP Code                                    City, State, ZIP Code

   Email Address                                                                 Telephone Number   

1.  Have you ever resided in Vermont with the intention of making it your home?
   If Yes, when did you take up residency in Vermont (month/year)?   ________________________________________
   If No, please explain your connections with the State of Vermont (place of birth, school attendance, etc.). _________
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________
2. If you once resided in Vermont, did you leave not intending to return and did you take up residence in another state with 
   the intention of making that state your home?
     Never resided in Vermont.  Go to Question 3.
     No.  Go to Question 3.
     Yes.       2a.     Date you moved from Vermont   ________________________________________________________
                 2b.     Address to which you moved  __________________________________________________________
                 2c.     Date on which you took up residence in the new state _______________________________________
                 2d. What specific steps did you take to abandon your legal residence in Vermont? ____________________
                          __________________________________________________________________________________  
                          __________________________________________________________________________________
                 2e.     What specific steps did you take to establish your new legal residence (examples: drivers license, voter 
                         registration, vehicle registration)? _______________________________________________________
                          __________________________________________________________________________________
                          __________________________________________________________________________________
3. Did you reside in two or more homes during the year?
   No.  Go to Question 4.
     Yes.  Please state the address and dates on which you were physically present in each location:
                                                                                                              Total number 
                     Physical Address (street, city, state)                      Periods (Dates)              of days
    ________________________________________________                             ___________________________   __________
    ________________________________________________                             ___________________________   __________
    ________________________________________________                             ___________________________   __________

                                                                                                 Domicile Statement
                                                                                                          Page 1 of 3
                                                                                                          Rev. 04/19

  Your Name                                                       Social Security Number For the taxable period ending

4. Do you own or rent a house or apartment?
   No.  Go to Question 5.
     Yes.                                                                Property Value            # of days spent 
                     Physical Address                    Own/Rent                        (if owned) here last year
   4a.  _____________________________________________   _________    ______________   _______________
   4b.  _____________________________________________   _________    ______________   _______________
   4c.   _____________________________________________   _________    ______________   _______________
5. Where do members of your immediate family live (spouse or CU partner, children)? __________________________
    _____________________________________________________________________________________________
6.  If married or civil union, did the physical presence of your spouse/partner and family differ substantially from yours?
     Single   No     Yes.  Please explain and attach a separate Domicile Statement for your spouse/CU partner.
                            ______________________________________________________________________
                            ______________________________________________________________________
                            ______________________________________________________________________
                            ______________________________________________________________________
7. Did you claim a homestead property tax exemption for any state?
   No.  Go to Question 8.
     Yes.  What state(s)? __________________________________________________________________________
8. Where are the items or possessions that you consider important to you located, e.g.: items of significant sentimental 
   value, family heirlooms, collections of valuables, pets, or possessions that enhance the quality of your life?
             Item/Possession                                      Location
    ________________________________        _________________________________________________________
    ________________________________        _________________________________________________________
    ________________________________        _________________________________________________________
    ________________________________        _________________________________________________________
9.  In what State(s) did you or your Spouse/CU Partner perform services for compensation (work)?
   State                                   Employer                                                 Date of Employment
Self:
________________      _______________________________________________________             __________________
________________      _______________________________________________________             __________________
________________      _______________________________________________________             __________________
Spouse or CU Partner:
________________      _______________________________________________________             __________________
________________      _______________________________________________________             __________________
________________      _______________________________________________________             __________________
10. Do you own any part of a business?
   No.  Go to Question 11.
     Yes.  10a. Where is the business located?  ________________________________________________________
            10b. What is your ownership percentage? ____________________________________________________

                                                                                         Domicile Statement
                                                                                                    Page 2 of 3
                                                                                                    Rev. 04/19

 Your Name                                                        Social Security Number  For the taxable period ending

11. Where did your children attend school?  List name and address of school(s).  ________________________________
     _____________________________________________________________________________________________
     _____________________________________________________________________________________________
12. What address did you use for mailing purposes and why?  _______________________________________________
     _____________________________________________________________________________________________
13. What address did you use on your federal tax return(s) and why?  _________________________________________
     _____________________________________________________________________________________________
14. Please list the state(s), if any, with which you filed income tax return(s) for the taxable year and enclose a copy of the 
    return(s) ______________________________________________________________________________________
15. During the taxable year, did you have:                                               State(s)
    a. A House or Apartment ...........................            No       Yes  ______________________
    b. Vacation House  ................................            No       Yes  ______________________
    c. Driver’s License (attach copy) .....................        No       Yes  ______________________
    d.  Automobile/Power Boat/Snow Machine Registration ...        No       Yes  ______________________
    e. Aircraft .......................................            No       Yes  ______________________
    f. Voting Registration  .............................          No       Yes  ______________________
    g. Bank Accounts .................................             No       Yes  ______________________
    h. Resident Hunting and Fishing Licenses ..............        No       Yes  ______________________
    i. Golf Club/Rod & Gun Club Membership(s) ..........           No       Yes  ______________________
    j.  Location of Doctor and Medical Records ............        No       Yes  ______________________
    k. Civic, religious, or community clubs or activities ......   No       Yes ______________________
           [List Organization(s) AND State(s)] ____________________________________________________
            _________________________________________________________________________________
            _________________________________________________________________________________
16. Are you a member of the Armed Services? .....        No.  Skip Question 17 and go to Question 18.
                                                         Yes, Active Duty   Yes, Reserve
17. Did you enter the service from Vermont?. . . . . .   No        Yes
18. You may use this space, or attach a separate page to explain your answers or to make any additional statements that could 
    help us in arriving at a proper conclusion. ____________________________________________________________
     _____________________________________________________________________________________________
     _____________________________________________________________________________________________
     _____________________________________________________________________________________________  
     _____________________________________________________________________________________________

           Under penalties of perjury, I declare that I have examined this document and accompanying statements, and to the best 
           of my knowledge and belief, they are true, correct and complete.

    Taxpayer’s Signature                                          Date                   Daytime Telephone Number

    Spouse’s Or CU Partner’s Signature                            Date                   Daytime Telephone Number

                                                                                         Domicile Statement
                                                                                                         Page 3 of 3
                                                                                                         Rev. 04/19

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