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In Part I, enter the name and complete address of the nonresident contractor. Include the Connecticut tax registration number and select the type of organization by checking the appropriate box.
Proceed to Part II and specify the two-year verification period by entering the start date as January 1st of the requested year and the end date as December 31st of the following year.
For Part III, provide details about the person doing business with the nonresident contractor. Fill in their name, project name, commencement date, and contract dollar amount for all known or proposed contracts during this verification period.
In Part IV, ensure that all conditions are met for approval as a ‘verified contractor’. Confirm registration for applicable taxes, filing of required tax returns, and absence of outstanding tax liabilities.
Finally, sign and date the declaration section at the bottom of the form before submitting it to the Department of Revenue Services.

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