EFTA01219704.pdf

Please scroll down for the form at the bottom of this page. Review the form for accuracy. Remember to detach the form before mailing to the agency. (CUT HERE) STATE OF RHODE ISLAND DIVISION OF TAXATION @ DEPTVXO @PO BOX 970? qi PROVIDENCE. RI 0-910.910) WITHHOLDING TAX RETURN MONTHLY WTM I HEREBY CERTIFY THAT THIS RETURN. TO THE BEST OF MY KNOWLEDGE AND BELIEF. IS A TRUE. CORRECT MC COMPLETE RETURN. SIGNATURE OF OWNER, PARTNER OR AUTHORIZED AGENT TTTLE DATE TAX AMOUNT ACCOUNT IDENTIFICATION NUMBER RETURN FOR MONTH ENDING DUE AND PAID 941d/RI REV 11/99 EFTA01219704