Fill and Sign the At the Same Time the City of Boston Awards a Service Contract through a Bid a Form

Department of Revenue Services State of Connecticut PO Box 2930 Hartford CT 06104-2930 Form CT-6559 Submitter Report for Form W-2 Magnetic Media Filing (Rev. 10/04) Forms CT-W3 must accompany this form. 1. Type of file represented by this transmittal 2. Calendar year for which media is submitted Original 3. Submitter’s Connecticut Tax Registration Number Replacement 4. Name and address of submitter (Include street, PO box, city, state, and ZIP code) 5. Submitter’s Federal Employer Identification Number 6. Name and address of person to contact about this magnetic media file 7. Contact telephone number (include area code) ( 8. Type of media submitted Cartridge ) 9. Total number of media in shipment Diskette 10. Total number of employers CD-ROM 11. Total number of employees 12. Submitter’s magnetic media inventory numbers In general, the employer must sign the declaration; however, an authorized agent of the employer 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 to DRS is a fine of not more than $5,000, or imprisonment for not more than five 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 13. Employer Summary of Form W-2 Magnetic Media Wage Information Date 13. Employer Summary of Form W-2 Magnetic Media Wage Information Name of Employer Name of Employer Street Address Street Address City State ZIP City State Connecticut Tax Registration Number Connecticut Tax Registration Number Federal Employer ID Number Federal Employer ID Number Number of W-2s Submitted Number of W-2s Submitted Form W-2 - Connecticut Summary Form W-2 - Connecticut Summary Total Connecticut Wages Reported Total Connecticut Wages Reported Connecticut Tax Withheld From Wages Connecticut Tax Withheld From Wages 13. Employer Summary of Form W-2 Magnetic Media Wage Information 13. Employer Summary of Form W-2 Magnetic Media Wage Information Name of Employer Name of Employer Street Address Street Address City State ZIP City State Connecticut Tax Registration Number Connecticut Tax Registration Number Federal Employer ID Number Federal Employer ID Number Number of W-2s Submitted Number of W-2s Submitted Form W-2 - Connecticut Summary ZIP ZIP Form W-2 - Connecticut SummaryT Total Connecticut Wages Reported Total Connecticut Wages Reported Connecticut Tax Withheld From Wages Connecticut Tax Withheld From Wages Instructions Use Form CT-6559, Submitter Report for Form W-2 Magnetic Media Filing, to identify the submitter of a magnetic media file. For W-2 magnetic media reporting, a file is a report that begins with a code RA submitter record and ends with a code RF submitter record. Department of Revenue Services State of Connecticut PO Box 2930 Hartford CT 06104-2930 If a PO Box cannot be used, send to: Block 3: Enter the ten-digit tax registration number assigned by the Connecticut Department of Revenue Services (DRS) to the submitter, if applicable. Block 5: Enter the nine-digit Federal Employer Identification Number (FEIN) assigned to the submitter by the IRS. Block 10: Enter the total number of employers covered by this submittal. Form CT-W3, Connecticut Annual Reconciliation of Withholding, must be included for each employer. Block 11: Enter the total number of employees (as entered on the code RF final record). Block 12: Enter the inventory number for each cartridge, diskette, or CD-ROM in this file. The inventory number is any type of number assigned by the submitter to the cartridge, diskette, or CD-ROM for the submitter’s own inventory control purposes. If this is a multi-volume file, list the numbers in order. If this block is not applicable, leave blank. Block 13: Complete Block 13, Employer Summary of Form W-2 Magnetic Media Wage Information, for each employer included in the magnetic media file. If reporting data for more than four employers, use the additional Block 13 areas on Form CT-6559A. Substitute Forms CT-6559 and CT-6559A: DRS encourages the use of computer-generated substitutes for Forms CT-6559 and CT-6559A. The format must include all information requested on those forms, including the declaration. Mailing Address: Prepare Form CT-6559 for each separate magnetic media file being submitted. Send the magnetic media in the same package with Forms CT-6559, CT-6559A (if applicable), and CT-W3 to the address at right. Department of Revenue Services State of Connecticut Attn: Processing II, 15th Floor 25 Sigourney Street Hartford CT 06106-5032 Declaration Instructions A submitter, service bureau, paying agent, or disbursing agent (agent) may sign Form CT-6559 on behalf of the payer (or other person required to file), if both conditions below are met: 1. The agent has the authority to sign the form under an agency agreement (oral, written, or implied) that is valid under state law; and 2. The agent signs the form and adds the caption “For: (Name of the payer or other person required to file).” If an authorized agent signs the declaration on the employer’s behalf, this does not relieve the employer of the responsibility for filing a correct, complete, and timely Form CT-6559, with attachments, and does not relieve the employer of any penalties for not complying with those requirements. Forms and Publications Forms and publications are available anytime at: • Internet: Preview and download forms and publications from the DRS Web site at www.ct.gov/DRS • DRS TAX-FAX: Call 860-297-5698 from the handset attached to your fax machine and select from the menu. Only forms (not publications) are available on TAX-FAX. • Telephone: Call 1-800-382-9463 (in-state) and select Option 2; or the Forms Unit at 860-297-4753 (from anywhere). Magnetic Media Specifications for W-2 Reporting Cartridge Requirements • 3480 or 3490 cartridge • 512 byte fixed length records Cartridge Recommendation • 45 records per block (23,040) • EBCDIC character set Character Set - Check one ASCII ............................... EBCDIC ........................... CT-6559 Back (Rev. 10/04) Diskette Requirements • PC compatible • 512 byte fixed length records • 3 1/2 inch (720K, 1.44M densities) CD-ROM Requirements • Formatted as Data CD-ROM • 512 byte fixed length records Character Set - Check one Character Set - Check one ASCII .............................. EBCDIC .......................... ASCII ............................... EBCDIC ...........................