Gc-22(H) / State Form 49101 - Indiana Governmental Units And Agencies Report Of Construction And Other Service Contracts
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1Indiana Department of Revenue
Indiana Governmental Units and Agencies Report of Construction and Other Service Contracts
Name of Agency
This report must be filed within 30 days
of executing a construction contract.
Form GC-22(h)
Street Address
County
Revised 9/99
State Form 49101
City or Town, State and Zip Code
Telephone No.
Agency Federal I.D.#
Period covered in this report
from ____________ to _____________
Attach additional sheets if necessary.
Federal Identification
Name and Address of Contractor,
Description of Project
Date of
Amount of
Amount of Gross
Date of
1
2
3
4
5
6
7
Number or Social
known Subcontractors
Contract
Contract
Income Tax Withheld
Gross
Security Number
Designers, Engineers, etc.
(in dollars)
on Nonresident
Income Tax
without Deductions
Contractors
Remittance
Mail to:
Page ______ of _______
INDIANA DEPARTMENT OF REVENUE
COMPLIANCE DIVISION
P.O. BOX 935
INDIANAPOLIS, INDIANA 46206-0935
Signature of Officer(s)
Title
Date
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