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STATE OF CONNECTICUT

DEPARTMENT OF REVENUE SERVICES

(Rev. 12/99)

The attached Annual Reconciliation of Withholding may be used by new payers and payers who have not received the Employer’s Withholding Remittance

Coupon Book for 2000.

Form CT-1096 (DRS), Connecticut Annual Summary and Transmittal of Information Returns , must be filed by certain payers

who are required to file federal Form 1096. Form CT-1096 is

. No payment is to be made with this form.

If you are required to file a federal Form 1096, you must file a Form CT-1096 with every “state copy” of the following:

– federal Form W-2G, for winnings paid to resident individuals, even if no Connecticut income tax was withheld;

– federal Form 1099-MISC, for payments to resident individuals, or to nonresident individuals, if the payments relate to services performed wholly or partly

in Connecticut, even if no Connecticut income tax was withheld;

– federal Form 1099-R,

if Connecticut income tax was withheld;

– federal Form 1099-S, reporting real estate transactions in Connecticut.

The above federal forms must be filed even if you are not required to be registered with DRS. Unregistered filers should write “Information Only” in the space

reserved for the Connecticut Tax Registration Number on this form.

Mail your completed return to: Department of Revenue Services

PO Box 5081

Hartford CT 06102-5081

CONNECTICUT TAX REGISTRATION NUMBER

FEDERAL EMPLOYER ID NUMBER

DUE DATE

1. Connecticut income tax withheld from

Enter name and address below. Please print or type.

nonpayroll amounts (See Instructions)

2. Total nonpayroll amounts reported with

this Form CT-1096 (See instructions)

1 2 3 4 5

3. Number of 1099s and W-2Gs submitted

1 2 3 4 5

NOTE: DO NOT MAKE PAYMENT WITH THIS FORM.

MAIL TO:

DEPARTMENT OF REVENUE SERVICES

PO BOX 5081

HARTFORD CT 06102-5081

I declare under the penalty of false statement that I have examined this return and, to

the best of my knowledge and belief, it is true, complete and correct. (The penalty for

false statement is imprisonment not to exceed one year or a fine not to exceed two

thousand dollars, or both.)

Signature __________________________________________________________

Title ______________________________________ Date __________________

SEPARATE HERE AND MAIL COUPON TO DEPARTMENT OF REVENUE SERVICES. KEEP THE TOP PORTION FOR YOUR RECORDS.

CONNECTICUT TAX REGISTRATION NUMBER

FEDERAL EMPLOYER ID NUMBER

DUE DATE

1. Connecticut income tax withheld from

Enter name and address below. Please print or type.

nonpayroll amounts (See Instructions)

2. Total nonpayroll amounts reported with

this Form CT-1096 (See instructions)

1 2 3 4 5

3. Number of 1099s and W-2Gs submitted

1 2 3 4 5

NOTE: DO NOT MAKE PAYMENT WITH THIS FORM.

MAIL TO:

DEPARTMENT OF REVENUE SERVICES

PO BOX 5081

HARTFORD CT 06102-5081

I declare under the penalty of false statement that I have examined this return and, to

the best of my knowledge and belief, it is true, complete and correct. (The penalty for

false statement is imprisonment not to exceed one year or a fine not to exceed two

thousand dollars, or both.)

Signature __________________________________________________________

Title ______________________________________ Date __________________

Form Ct-1096 (Drs) - Connecticut Annual Summary And Transmittal Of Information Returns 2000

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