Ets Form 120 - Non-Resident Subcontractor Information Report

Ets Form 120 - Non-Resident Subcontractor Information Report - 2002

State of Wyoming

The Department of Revenue

Excise Tax Division

Herschler Building, 122 West 25th Street

Cheyenne, Wyoming 82002-0110

(307) 777-5200

Non-Resident Subcontractor Information Report

Please note that the prime contractor must complete and submit this form for each non-resident subcontractor whenever a

subcontract is awarded and/or added to any Wyoming Contract Project.

This report refers only to subcontractors who provide labor, equipment, materials and supplies in the fulfillment of a

subcontract to alter, improve or construct real property. It does not refer to vendors who supply materials only.

1. Subcontractor Name:

2. FEIN/SS:

3. Phone #:

FAX #:

4. Contact Name:

5. Mailing Address:

City

State

Zip

6. Type of Contract (Electrical, Plumbing, Heating, etc.):

Note: You must enclose a copy of the bid contract that describes the scope of work you were hired to

perform.

7. This contract will be for: Labor and Materials:

Labor Only:

8. Amount of Contract: $

a) Lower Tier Sub to:

9. Date Subcontract Awarded:

10. Anticipated Start Date of contract:

11. Anticipated Completion Date:

12. Project Name:

13. Project Location (City/County):

14. General or Prime Contractor:

15. Address:

Authorized Signature:

Phone #:

Fax #:

Printed Name:

Title:

(This form may be duplicated as needed)

ETS Form 120 Rev 05/30/02

Ets Form 120 - Non-Resident Subcontractor Information Report - 2002