Form Au-964 - Surety Bond And Release
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1
2Department of Revenue Services
Compliance Support Unit
Form AU-964
25 Sigourney Street Ste. 2
Hartford CT 06106-5032
Surety Bond and Release
New (10/01/2011)
Purpose: A registered nonresident prime or general contractor working in Connecticut, and a surety company licensed to do business in Connecticut,
use Form AU-964 to post a surety bond for a specific project over $250,000 to ensure all taxes due to the State of Connecticut from the contract,
including all subcontractors directly under the prime or general contractor are paid to Department of Revenue Services (DRS). Read the instructions on
the reverse side before you complete this form. If you need assistance, call 860-541-7538, Monday through Friday, during business hours.
Part I: Nonresident Prime or General Contractor Information
Name
Connecticut Tax Registration No.
Address (Street or PO Box, City, State, and ZIP Code)
Part II: Customer of Nonresident Prime or General Contractor (owner, lessee, or other person having authority to enter into a contract)
Name
Address (Street or PO Box, City, State, and ZIP Code)
Part III: Surety Company Information
Name
Bond No.
Bond Amount, 5% of Total Contract Price
Address (Street or PO Box, City, State, and ZIP Code)
Part IV: Project Information
Check if this bond is for a change order.
Physical Location of Project (Street, City or Town)
Name of Project
Commencement Date
Completion Date
Total Contract Price not to be less than $250,000
Conditions of the obligation for the project detailed above:
The nonresident prime or general contractor has entered into a contract related to real property at a Connecticut location for a contract
price of $250,000 or more.
The nonresident prime or general contractor and the surety company are posting a bond of 5% of the total contract price, including any
change orders and add-ons, with DRS to ensure that all taxes that become due and owing during the period of the contract will be paid.
If the nonresident prime or general 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 prime or general contractor and the surety company, their heirs, executors,
administrators, successors, and assigns for payment of this obligation.
Nonresident Prime or General Contractor Declaration: I, an authorized agent of the nonresident prime or general contractor, declare under
the penalty of law that I have examined Form AU-964 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-964 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
~~ For DRS Use Only ~~
Release by Authorized DRS Agent: I, an authorized agent of the DRS, have examined the tax liabilities covered by this Form AU-964 and am
releasing the nonresident prime or general contractor named above and the surety named from this bond related to the project and timeframe
described above. The DRS will retain the original copy of this form.
Print Name
Title
Stamp:
Authorized Signature
Date
Form AU-964
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