Form Au-409 - Transmittal Form For Submission Of Interest Income Information - Connecticut Department Of Revenue Services
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1Department of Revenue Services
State of Connecticut
25 Sigourney Street
Hartford CT 06106
Transmittal Form for Submission of Interest Income Information
Name of Transmitter:
Federal Employer Identification Number (FEIN):
Address 1:
Address 2:
City:
State:
ZIP:
Is transmitter acting as a service bureau for other payers?
Yes
No
If “yes,” list the names of all payers.
1.
7.
2.
8.
3.
9.
4.
10.
5.
11.
6.
12.
Technical Contact Person:
Phone: (
)
Customer Representative:
Phone: (
)
Address 1:
Address 2:
State:
City:
ZIP:
Tax Year:
Number of Volumes:
Total:
Diskettes:
Software Used:
Tapes:
Recording Mode:
EBCDIC
ASCII
Block Size:
Density:
Label Information:
Non Label:
1.
2.
3.
Label Numbers
4.
5.
6.
Mail To:
Department of Revenue Services
State of Connecticut
25 Sigourney Street
Hartford CT 06106
Attention: James Lynch, EDP Audit Unit
AU-409 (Rev. 5/02)
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