Form Ic134 - Withholding Affidavit For Contractors

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IC134

Withholding Affidavit for Contractors

This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of its subdivisions

can make final payment to contractors. For more detailed information, see the instructions on the back of this form.

Please type or print clearly. This will be your mailing label for returning the completed form.

Company name

Daytime phone

Minnesota tax ID number

Address

Total contract amount

Month/year work began

City

State

ZIP code

Amount still due

Month/year work ended

Project number

Project location

Project owner

Address

City

State

ZIP code

Did you have employees work on this project?

Yes

No. If no, who did the work?

Check the box that describes your involvement in the project and fill in all information requested.

Sole contractor

Subcontractor

Name of contractor who hired you

Address

Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must file their own IC134 affida-

vits and have them certified by the Department of Revenue before you can file your affidavit. For each subcontractor you had, fill

in the information below and attach a copy of each subcontractor’s certified IC134. If you need more space, attach a separate

sheet.

Business name

Address

Owner/Officer

I declare that all information I have filled in on this form is true and complete to the best of my knowledge and belief. I authorize the Department of Revenue to

disclose pertinent information relating to this project, including sending copies of this form, to the prime contractor if I am a subcontractor, and to any subcon-

tractors if I am a prime contractor, and to the contracting agency.

Contractor’s signature

Title

Date

Mail to: Minnesota Revenue, Mail Station 6610, St. Paul, MN 55146-6610

Phone: 651-282-9999 or 1-800-657-3594 (TTY: Call 711 for Minnesota Relay).

Certificate of Compliance

Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has ful-

filled all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income tax from

wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions.

Department of Revenue approval

Date