Form Ct-4804 - Transmittal Of Informational Returns Reported On Compact Disc (Cd)
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1Department of Revenue Services
Form CT- 4804
For DRS Use Only
State of Connecticut
PO Box 5081
Transmittal of Informational Returns
Hartford CT 06102-5081
Reported on Compact Disc (CD)
(Rev. 09/08)
For Forms W-2G, 1099-R, and 1099-MISC
.
Complete this form in blue or black ink only.
1. Type of fi le represented by this transmittal
2. Calendar year for which CDs are submitted
3. Transmitter’s Federal Employer ID Number (FEIN)
Original
Replacement
4. Name of transmitter
5. Total number of CDs in shipment
6. Company name, address, and name and title of person to contact about problem fi les
7. Combined total number of payer records reported
(street, city, state, and ZIP Code)
Telephone number (
)
8. Payer Summary of CD Wage Informational Returns.
8 A
Payer 1 Summary Information
8 B
Payer 2 Summary Information
Name of payer
Name of payer
Street address
Street address
City
State
ZIP Code
City
State
ZIP Code
Connecticut Tax Registration Number
Connecticut Tax Registration Number
FEIN
FEIN
Type of return
Type of return
Number of 1099s or W-2Gs submitted
Number of 1099s or W-2Gs submitted
Total nonpayroll amounts reported
Total nonpayroll amounts reported
Connecticut tax withheld
Connecticut tax withheld
8 D
Payer 4 Summary Information
8 C
Payer 3 Summary Information
Name of payer
Name of payer
Street address
Street address
City
State
ZIP Code
City
State
ZIP Code
Connecticut Tax Registration Number
Connecticut Tax Registration Number
FEIN
FEIN
Type of return
Type of return
Number of 1099s or W-2Gs submitted
Number of 1099s or W-2Gs submitted
Total nonpayroll amounts reported
Total nonpayroll amounts reported
Connecticut tax withheld
Connecticut tax withheld
In general, the payer must sign the declaration below; however, an authorized agent of the payer may sign if all conditions stated on the
back are met.
Declaration: I declare under the 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 the penalty for willfully delivering a false return
or document to the Department of Revenue Services (DRS) is a fi ne of not more than $5,000, or imprisonment for not more than fi ve years,
or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
Signature
Title
Date
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