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Enter the total amount of Connecticut income tax withheld from nonpayroll amounts during the calendar year. (This should equal the Total

Line on the back of this form.) Nonpayroll amounts are the amounts required to be reported on Line 2.

Enter the total amount of gross winnings from federal Forms W-2G, miscellaneous income from federal Forms 1099-MISC, distributions from

federal Forms 1099-R and proceeds from federal Forms 1099-S reported with this return.

Indicate the number of federal Forms W-2G, 1099-MISC, 1099-R and 1099-S submitted with this return.

Be sure to complete all requested information below. Sign and date the return in the space provided.

All payments must be made using Forms CT-WH and CT-941.

If you are required by the IRS to file copies of federal Forms 1099, W-2G or both, on magnetic media, you must file these forms on magnetic

media with DRS. However, if you file 24 or fewer Forms 1099, W-2G or both, with DRS, you may be excused from the magnetic media filing

requirements for that particular type of information return without obtaining a waiver. For new information regarding magnetic media reporting

requirements, visit the DRS Web site at or call DRS at: 1-800-382-9463 (toll free from within Connecticut) or 860-297-5962

(from anywhere). TTY, TDD and Text Telephone users

may transmit inquiries by calling 860-297-4911.

If you are required to file a federal Form 1096, you must file a Form

CT-1096. Attach 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

CONNECTICUT INCOME TAX WITHHELD

withheld;

PERIOD

- federal Form 1099-R,

if Connecticut income tax was withheld;

FROM NONPAYROLL AMOUNTS

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

JANUARY 1 -

If you are required by the IRS to file copies of federal Forms 1099, W-2G or

1st QUARTER

MARCH 31

both, on magnetic media, you

file these forms on magnetic media with

DRS. However, if you file 24 or fewer Forms 1099, W-2G or both, with

APRIL 1 -

DRS, you may be excused from the magnetic media filing requirements

2nd QUARTER

JUNE 30

for that particular type of information return without obtaining a waiver.

For new information regarding magnetic media reporting requirements,

JULY 1 -

visit the DRS Web site at or call DRS at:

SEPTEMBER 30 3rd QUARTER

1-800-382-9463 (toll free from within Connecticut) or

860-297-5962 (from anywhere)

OCTOBER 1 -

TTY, TDD and Text Telephone users

may transmit

4th QUARTER

DECEMBER 31

inquiries by calling 860-297-4911.

This should equal

on the front of this form.

CT-1096 (DRS) Back (Rev. 12/99)