File your Connecticut W-1130 form to claim the state's film production tax credit. The tax credit is available to businesses that produce films, television programs, and digital media in Connecticut. You may be able to claim the credit for up to 25% of the qualified production costs incurred in Connecticut. There are several requirements that must be met in order to qualify for the credit, so make sure you understand the guidelines before you start filming.
| Question | Answer |
|---|---|
| Form Name | Connecticut Form W 1130 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | w1130ABIRequest Form acquired brain injury abi waiver request form |
STATE OF CONNECTICUT |
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(Rev. 2/07) |
DEPARTMENT OF SOCIAL SERVICES |
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ACQUIRED BRAIN INJURY (ABI) WAIVER REQUEST FORM |
1.Personal Data
Name |
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Social Security # |
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Address |
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No. |
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Telephone ( |
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Age |
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Single |
Married |
Widowed |
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State |
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Zip Code |
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Date of Birth |
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(month) |
(day) |
(year) |
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Divorced |
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Contact person if other than yourself:
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Telephone |
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Apt. No. |
City
Relationship
(check all that apply)
State
Conservator of Person
Other (specify)
Zip Code
Conservator of Estate
2.ABI Information
Do you have an acquired brain injury?
If Yes, please indicate date of injury |
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Yes
⁄
No
and diagnosis
3.Freedom of Choice - Please read the following and check the box that indicates your choice
If possible, I would prefer to live in the community rather than a nursing home or other institutional setting.
I would prefer to live in a nursing home or other similar setting.
4.Medicaid (Title 19) and Medicare Information
Please check the blocks that apply to you:
I am receiving Medicare benefits (enter claim number)
I am receiving Medicaid/Title 19 benefits (enter case number)
I have a Medicaid "Spenddown" (enter case number, if known)
I have applied for Medicaid benefits but have not received a decision
I have not applied for Medicaid benefits
THIS INFORMATION IS AVAILABLE IN ALTERNATE FORMATS. PHONE (800)
(800)
5.Financial Data
My total monthly income (for example, Social Security, SSI, disability benefits, pension benefits, Workers Compensation, wages, contributions, income from interest or dividends, etc.) is:
Amount |
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Source |
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My total assets (for example, cash, bank accounts, IRAs, life insurance, annuities, stocks, bonds, motor vehicles, property, etc.)
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Amount |
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Source |
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Signature of Applicant |
Date |
Signature of Conservator or Other Representative |
Date |
Typed or Printed Name of Conservator or Other Representative |
Date |
Return This Form To:
Department of Social Services
25 Sigourney Street
Hartford, CT
Attention: Social Work Services
10th Floor