Form 120 - Non-Resident Subcontractor Information Report printable pdf download

*0-0-702-099*

Wyoming Department of Revenue

Excise Tax Division

122 W. 25th Street, Herschler Bldg.

Cheyenne, Wyoming 82002-0110

Non-Resident Subcontractor Information Report

Please note that the prime contractor must complete and submit this form for each non-resident subcontractor whenever a subcontract is awarded

and/or added to any Wyoming Contract Project.

This report refers only to subcontractors who provide labor, equipment, materials and supplies in the fulfillment of a subcontract to alter, improve

or construct real property. It does not refer to vendors who supply materials only.

1. Subcontractor Name: ____________________________________________________2. FEIN/SS:___________________________________

3. Phone #: ________________________________________________FAX #:_____________________________________________________

4. Contact Name:______________________________________________________________________________________________________

5. Mailing Address: ______________________________________City __________________________State___________ Zip______________

6. Type of Contract (Electrical, Plumbing, Heating, etc.):

Note: You must enclose a copy of the bid contract that describes the scope of work you were hired to perform.

7. This contract will be for: Labor and Materials:___________________________ Labor Only:_______________________________

8. Amount of Contract: $___________________________________________________________

a) Lower Tier Sub to:_______________________________________________________

9. Date Subcontract Awarded:_______________________________________________________

10. Anticipated Start Date of contract:_________________________________________________

11. Anticipated Completion Date:____________________________________________________

12. Project Name:______________________________________________________________________________________________

13. Project Location (City/County):________________________________________________________________________________

14. General or Prime Contractor:

15. Address:___________________________________________________________________________________________________

Authorized Signature: ____________________________________Phone #: _____________________Fax#:_______________________

Printed Name:_________________________________________ Title:_____________________________________________________

(This form may be duplicated as needed)

ETS Form 120 Rev 4/25/11

Form 120 - Non-Resident Subcontractor Information Report