Form Au-961 - Verification Bond
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1
2Department of Revenue Services
Compliance Support Unit
Form AU-961
25 Sigourney Street, Ste. 2
Verification Bond
Hartford CT 06106-5032
New (10/01/2011)
Purpose: A nonresident contractor working in Connecticut must use Form AU-961 to post a verification bond covering the verification period
specified below from a surety company licensed to do business in Connecticut before it is eligible to become a verified contractor with the
Department of Revenue Services (DRS). The verification bond ensures all taxes due to the State of Connecticut from the contractor are paid to
DRS for the two-year period during which the nonresident contractor is considered “verified” by the DRS. Form AU-960, Nonresident
Contractor Request for Verified Contractor Status, must be submitted with Form AU-961. Prior to completing refer to the instructions on the
reverse. For assistance, call 860-541-7538, Monday through Friday, during business hours.
Part I: Nonresident Contractor Information
Name
Connecticut Tax Registration No.
Address (Street or PO Box, City, State, and ZIP Code)
Part II:
Surety Company Information
Name
Bond #
Address (Street or PO Box, City, State, and ZIP Code)
Column A
Column B
Column C
Total actual or proposed gross receipts
Multiply Column A by 2
Multiply Column B by 5% (.05),
during verification period
(if result is less than $10,000 enter $10,000)
Part III: Verification Period
(Two-Year Period)
January 1, 20__ __
through
December 31, 20__ __
Part IV: Conditions of the obligation:
The nonresident contractor has entered into a contract or contracts related to real property at a Connecticut location.
The nonresident contractor and the surety company are posting a bond of 5% to cover two times any proposed or actual work to occur
within the verification period.
If the nonresident contractor pays all taxes, interest, and penalties within three years from the last day of the month succeeding the
reporting period in which the contractor posted the bond, the bond expires; otherwise the obligation remains in full force.
This bond jointly and severally binds the nonresident contractor and the surety company, their heirs, executors, administrators,
successors, and assigns for payment of this obligation.
Nonresident Contractor Declaration:
I, an authorized agent of the nonresident contractor named above, declare under the penalty of
law that I have examined Form AU-961 and, to the best of my knowledge and belief it is true, complete, and correct. I understand the penalty
for willfully delivering a false document or return to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
Print Name
Title
Authorized Signature
Date
Surety Company Declaration:
I, an authorized agent of the surety company named above, declare under the penalty of law that I have
examined this Form AU-961 and, to the best of my knowledge and belief it is true, complete, and correct. I understand the penalty for willfully delivering
a false document or return to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
Print Name
Title
Raised Seal
Authorized Signature
Date
Form AU-961
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