Form Ct-19it is a legal form used to report an injury that resulted in the disability of the worker. The form is used to notify workers' compensation insurance and the state worker's compensation board. This form is also used to request benefits from the insurance company. Worker's compensation benefits may include medical expenses, income replacement, and death benefits. If you have been injured at work and are disabled, you should fill out this form as soon as possible. Speak to an attorney if you have any questions about filing a claim.
| Question | Answer |
|---|---|
| Form Name | Form Ct 19It |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | connecticut title 19 application pdf, title 19 application form ct, title 19 application, apply for title 19 |
Department of Revenue Services
State of Connecticut
25 Sigourney St Ste 2
Hartford CT
(Rev. 12/12)
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2012 |
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Title 19 Status Release |
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Place this form on top of your completed Connecticut income tax return. Complete in blue or black ink only.
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Purpose |
Who May Not File Form |
Use Form
Who May File Form
If you are required to file a Connecticut income tax return, you may file Form
1.You were a Title 19 recipient during the taxable year;
2.Medicaid assisted in the payment of your
3.You do not have the funds to pay your Connecticut income tax or income available from future earnings to pay the tax.
You may not use this form if you filed a joint return with your spouse. As joint filers, you are jointly and severally liable for payment of the tax. If one spouse is on Title 19, this does not relieve the other spouse from paying the full amount of tax due.
General Information
You are required to file a Connecticut income tax return if you meet any of the following conditions:
1.You meet the gross income test (See the instructions for Form
2.You had Connecticut income taxes withheld;
3.You made estimated tax payments to Connecticut or made a payment with Form
4.You had a federal alternative minimum tax liability.
Complete Form
If the recipient has given power of attorney to another person to file Connecticut income tax returns or other Connecticut tax forms on the recipient’s behalf, attach a copy of the Power of Attorney.
Signature of recipient
Date
Signature of person with power of attorney
Date
Name of person with power of attorney (print or type)