Department of Taxation and Finance
                                                                                                    IT-260.1
                 Change of Resident Status  – Special Accruals                                                                   (9/15)
                 Tax Law – Sections 639 and 1307

Complete this agreement in triplicate and forward by registered mail 
along with your securities, completed Form IT-201, IT-203, or IT-205,          INCOME TAX AUDIT ADMINISTRATOR I
and other required forms to the address shown on the right of this form.       IFDAB
                                                                               W A HARRIMAN CAMPUS
If filing a joint return, use both names.                                      ALBANY NY 12227-4299

  Whereas, I, (name)                                                                                                             , of
(address as shown on return)                                                                                                        , 
have changed my status for New York State and/or New York City personal income tax purposes from that of a resident to
that of a nonresident on (date)                                                  , and
  Whereas, I elect, pursuant to sections 639(a), 639(d), 639(e), 639(h), 1307(b), and 1307(e) of the Tax Law, to file my 
New York personal income tax return for the period prior to my change of residence on the cash receipts basis, and
  Whereas, the tax, as determined pursuant to sections 639(a), 639(d), 639(e), 639(h), 1307(b), 1307(c), 1307(e), and 
1307(f) for the taxable year, or portion of the taxable year prior to my change of residence would have been increased by the 
amount of $                               if such election had not been made, and
  Whereas, I hereby deposit with you the following described security:

 1.  Certificated U.S. Treasury bonds:
                                                                                                    Market value
                                          Registration or                      Par or               (as of date of filing with        
             Due                certificate number                           face value             Tax Department)
                                                                                 
 Attached and made part of this agreement is a properly completed U.S. Treasury Form PDF 1832,Special Form of 
 Assignment for U.S. Registered Definitive Securities, assigning said securities to the New York State Department of Taxation 
 and Finance.

 2.  Certificated New York State bonds or bonds of any political subdivision thereof: 
                                                                                                    Market value
                                                           Registration or              Par or      (as of date of filing with
             Description                  Due              certificate number           face value  Tax Department)

 Attached and made part of this agreement is a properly completed New York State Form AU-217, Assignment Separate 
 from Bond, assigning said securities to the New York State Department of Taxation and Finance.

 3.  Bank passbooks and/or certificates of deposit:
                                                                                                    If certificate of deposit,
                 Bank/financial institution                                    Amount               maturity date

 Attached and made part of this agreement is a letter prepared on the letterhead of the bank/financial institution and 
 signed by an officer thereof: a) identifying the passbooks or certificates of deposit by account number and confirming that 
 withdrawal of principal from the passbook or certificate of deposit will not be permitted without written consent from the New 
 York State Department of Taxation and Finance; and b) stating that any right of set-off which the bank/financial institution 
 may possess against the taxpayer resulting from a defaulted obligation of such taxpayer shall be subordinate to the interest 
 of the department in the passbook or certificate of deposit offered as collateral.

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IT-260.1 (9/15) (back)

 4.  Standby letter of credit:

              Issuer or confirming bank                          Amount                      Expiration date

 Attached and made part of this agreement is the irrevocable standby letter of credit made payable to the New York State 
 Department of Taxation and Finance.

 5.  Form W-2G, Certain Gambling Winnings:

 Attached and made part of this agreement is a copy of completed federal Form W-2G, which shows that New York State 
 taxes were withheld on the lottery payments.

           Now, therefore, I agree that (1) I will include in my New York personal income tax returns in subsequent taxable 
 years (or periods) all income and gain accrued prior to my change of residence, as if I had not changed my resident status 
 and will pay the tax thereon when due; (2) the period of limitation within which tax may be assessed, set forth in Tax Law 
 section 683, is hereby extended as provided by paragraph (2) of subsection (c) of such section, and I hereby agree that 
 the tax due may be assessed for any taxable year (or periods) at any time within three years after the tax return relating 
 to the last taxable year during which income or gain accruing prior to my change of residence is actually received has 
 been filed; and (3) if the New York State Department of Taxation and Finance determines (a) that I have failed to include 
 in my New York personal income tax return for any taxable year (or period) any item of income or gain that is required 
 to be included therein under the terms of this agreement, or to pay any tax required to be paid, or (b) that the security 
 filed herewith has or will become inadequate to properly secure payment of the tax, the full amount of income which is 
 accruable under sections 639(a), 639(e), 639(h), 1307(b), 1307(c), 1307(e), and 1307(f) of the Tax Law shall be accrued 
 to the portion of the taxable year prior to the change of residence and the additional tax for such period, as recomputed, 
 shall become due immediately. If such tax is not paid within 30 days after notice of such determination described in 
 (a) above has been mailed to me by ordinary mail, or if the security that has been determined, as described in (b) above, 
 to be inadequate to secure payment of the tax is not replaced with adequate security acceptable to the department within 
 30 days after notice of such determination has been mailed to me by ordinary mail, the New York State Department of 
 Taxation and Finance may sell, assign, transfer, withdraw or otherwise dispose of said security and apply the proceeds to 
 any unpaid portion of the tax deferred by reason of the election and any interest and penalties due thereon. The balance of 
 such proceeds, if any, shall be paid to me.

           The above described security is deposited with the understanding that: (1) in case no disposition is made 
 thereof under the terms of this agreement, such security will be returned to me at such time as the department determines 
 it is no longer needed as security by reason of the full or partial payment of the tax deferred as a result of the election 
 under sections 639(d), 639(h), 1307(b), 1307(c), 1307(e), and 1307(f); and (2) any interest accruing on said security shall 
 belong to me; and (3) in the case of certificated bonds, in coupon form, the coupons will be detached and forwarded to me 
 as they become due.

  Signature of taxpayer                                                                Date

  Spouse’s signature (if joint return)

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