Form Au-409 - Transmittal Form For Submission Of Interest Income Information
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1Department of Revenue Services
State of Connecticut
25 Sigourney Street
Hartford CT 06106
Transmittal Form for Submission of Interest Income Information
Name of transmitter:
Federal Employer Identification Number (FEIN):
Address 1:
Address 2:
City:
State:
ZIP code:
Is transmitter acting as a service bureau for other payers?
Yes
No
If “yes,” list the names of all payers.
1.
7.
2.
8.
3.
9.
4.
10.
5.
11.
6.
12.
Technical contact person:
Phone: (
)
Customer representative:
Phone: (
)
Address 1:
Address 2:
State:
City:
ZIP code:
Tax year:
Number of volumes:
Total:
Diskettes:
Software used:
Tapes:
Recording mode:
EBCDIC
ASCII
Block size:
Density:
Label information:
Non-label:
1.
2.
3.
Label numbers
4.
5.
6.
Mail To:
Todd Jefson
Department of Revenue Services
Compliance Technology Unit
25 Sigourney St - Ste 2
Hartford CT 06106-5032
AU-409 (Rev. 02/11)
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Parent category: Financial