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2002

FORM CT-1096 (DRS)

STATE OF CONNECTICUT

DEPARTMENT OF REVENUE SERVICES

CONNECTICUT ANNUAL SUMMARY AND

(Rev. 12/01)

TRANSMITTAL OF INFORMATION RETURNS

PLEASE READ INSTRUCTIONS ON BACK BEFORE COMPLETING THIS RETURN

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

Remittance Coupon Book for 2002.

Annual Reconciliation: 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 due the last day of February. No payment is to be made with this return.

If you are required to file federal Form 1096, you must file Form CT-1096. Attach 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 1098, for property taxes paid on real estate to a Connecticut municipality;

– 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, only if Connecticut income tax was withheld;

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

Group the forms by form number and send each group with a separate Form CT-1096.

The above federal forms must be filed with the Connecticut Department of Revenue Services 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 return.

Mail your completed return to: Department of Revenue Services, PO Box 5081, Hartford CT 06102-5081.

2002

CT-1096 (DRS) CONNECTICUT ANNUAL SUMMARY AND TRANSMITTAL OF INFORMATION RETURNS

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

Form CT-1096 (See instructions)

1 2 3 4 5

3. Number of 1098s, 1099s, and W-2Gs

1 2 3 4 5

submitted

1 2 3 4 5

NOTE: DO NOT SEND A PAYMENT WITH THIS RETURN.

TAXPAYER’S COPY

MAIL TO:

DEPARTMENT OF REVENUE SERVICES

PO BOX 5081

HARTFORD CT 06102-5081

I declare under penalty of law that I have examined this return (including any accompanying

schedules and statements) and, to the best of my knowledge and belief, it is true, complete,

and correct. I understand that the penalty for willfully delivering a false return to DRS is a fine

of not more than $5,000, or imprisonment for not more than five years, or both.

Signature __________________________________________________________

Title ______________________________________ Date __________________

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

2002

CT-1096 (DRS) CONNECTICUT ANNUAL SUMMARY AND TRANSMITTAL OF INFORMATION RETURNS

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

Form CT-1096 (See instructions)

1 2 3 4 5

3. Number of 1098s, 1099s, and W-2Gs

1 2 3 4 5

submitted

1 2 3 4 5

NOTE: DO NOT SEND A PAYMENT WITH THIS RETURN.

MAIL TO:

DEPARTMENT OF REVENUE SERVICES

PO BOX 5081

HARTFORD CT 06102-5081

I declare under penalty of law that I have examined this return (including any accompanying

schedules and statements) and, to the best of my knowledge and belief, it is true, complete,

and correct. I understand that the penalty for willfully delivering a false return to DRS is a fine

of not more than $5,000, or imprisonment for not more than five years, or both.

Signature __________________________________________________________

Title ______________________________________ Date __________________

Form Ct-1096 (Drs) - Connecticut Annual Summary And Transmittal Of Information Returns - 2002

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