EFTA01219702.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) z STATE OF RHODE ISLAND DIVISION OF TAXATION • DEPTII00 • PO BOX 9/03 • PROVIDENCE. RI 029/0.9703 WITHHOLDING TAX RETURN QUARTER/MONTHLY • WTQM I HEREBY CERTIFY THAT THIS RETURN. TOME BEST OF MY KNOWLEDGE AND BELIEF. IS A TRUE CORRECT AND COMPLETE RETURN. SIGNATURE OF OWNER. PARTNER OR AUTHORIZED AGENT TITLE DATE TAX AMOUNT ACCOUNT IDENTIFICATION NUMBER RETURN FOR QUARIERMONTHLY PERIOD DUE AND PAID ENDING • NI-QMR1 REV 11199 EFTA01219702