Form Au-764 - Deposit By A Person Doing Business With A Nonresident Contractor

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Department of Revenue Services
Form AU-764
State of Connecticut
Deposit by a Person Doing Business
Attn: Discovery Unit
25 Sigourney Street
With a Nonresident Contractor
Hartford CT 06106-5032
(New 09/03)
Purpose: A person doing business with a nonresident contractor uses Form AU-764 to deposit 5% of the total contract price
with the Department of Revenue Services (DRS) for a specific project in the state. The deposit ensures all taxes due to the State
of Connecticut from the contractor are paid to DRS. Read the instructions on the reverse side before you complete this form. If
you need help, call 860-541-3280, Monday through Friday, 8:00 a.m. to 5:00 p.m., and choose Option 7.
Part I: Nonresident Contractor Information
Name
Connecticut Tax Registration No.
Address (Street or PO Box, City, State, and ZIP Code)
Part II: Person Doing Business With a Nonresident Contractor Information
Name
Connecticut Tax Registration No., Federal ID No., or SSN
Address (Street or PO Box, City, State, and ZIP Code)
Part III: Project Information
Physical Location of Project (Street, City or Town)
Name of Project
Commencement Date
Completion Date for
Total Contract Price or Amount of Change Order
Amount of Deposit
o
Nonresident Contractor
Check the box if this deposit is for a change order
Conditions of the deposit for the project detailed above:
•
The nonresident contractor has entered into a contract related to real property at a Connecticut location.
•
The person doing business with the nonresident contractor is depositing 5% of the total contract price with DRS to
ensure all taxes that become due and owing during the period of the contract will be paid.
•
The deposit is made within 30 days of the completion of the project.
•
The deposit will be returned to the nonresident contractor upon written request by the contractor after DRS has examined
its records and determined all taxes, interest, and penalties due during the term of the contract have been paid.
•
The person doing business with the nonresident contractor must attach a copy of the final periodic billing to Form AU-764.
Declaration: I, an authorized agent of the person doing business with a nonresident contractor named above, declare under the
penalty of law that I have examined Form AU-764 and, to the best of my knowledge and belief it is true, complete, and correct.
I understand the penalty for willfully delivering a false document or return to DRS is a fine of not more than $5,000, or imprisonment
for not more than five years, or both.
Print Name
Title
Authorized Signature
Date
Receipt of Deposit: DRS acknowledges receipt of $ ___________________________________________ from the person
named above as doing business with a nonresident contractor related to real property at the Connecticut location noted above.
Signature of Authorized DRS Representative
Telephone
Date

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