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(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