Form Ct-4804 - Transmittal Of Informational Returns Reported On Compact Disc (Cd)
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1
2Department of Revenue Services
Form CT- 4804
For DRS Use Only
State of Connecticut
Transmittal of Informational Returns
PO Box 5081
Hartford CT 06102-5081
Reported on Compact Disc (CD)
(Rev. 12/14)
For Forms W-2G, 1099-R, and 1099-MISC
.
Complete this form in blue or black ink only.
Payers are required to fi le Forms 1099-R, 1099-MISC, and W-2G electronically. Payers using Form CT-4804 must have
a valid DRS waiver from the electronic requirement. See instructions.
1. File type
2. Calendar year reported on CDs
3. Transmitter’s Federal Employer ID Number (FEIN)
Original
Replacement
4. Number of CDs shipped
5. Number of payee records reported with transmission
6. Transmitter name
Street address
City
State
ZIP code
7. Person to contact if there is a problem processing the CD(s)
Name
Title
Telephone number
(
)
8. Payer summary of informational returns reported on CD. Complete for each payer transmitted.
Payer name
Payer name
Street address
Street address
City
State
ZIP Code
City
State
ZIP Code
Connecticut Tax Registration No.
FEIN
Connecticut Tax Registration No.
FEIN
Return type -1099-MISC 1099-R, W-2G No. of returns submitted
Return type -1099-MISC 1099-R, W-2G No. of returns submitted
$
Total nonpayroll amounts reported
$
Total nonpayroll amounts reported
$
Connecticut tax withheld
$
Connecticut tax withheld
Payer name
Payer name
Street address
Street address
City
State
ZIP Code
City
State
ZIP Code
Connecticut Tax Registration No.
FEIN
Connecticut Tax Registration No.
FEIN
Return type -1099-MISC 1099-R, W-2G No. of returns submitted
Return type -1099-MISC 1099-R, W-2G No. of returns submitted
$
Total nonpayroll amounts reported
$
Total nonpayroll amounts reported
$
Connecticut tax withheld
$
Connecticut tax withheld
See Declaration Requirements on Back.
Declaration: I declare under the penalty of law that I have examined this return (including any accompanying schedules and statements)
and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return
or document to the Department of Revenue Services (DRS) is a fi ne of not more than $5,000, or imprisonment for not more than fi ve years,
or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
Signature
Title
Date
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