Form Ri-1096pt - Pass-Through Withholding Return And Transmittal - 2015 Page 2

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State of Rhode Island and Providence Plantations

2015 Form RI-1096PT

15102999990102

Pass-through Withholding Return and Transmittal

Name

Federal employer identification number

SCHEDULE A -

CALCULATION FOR AN ENTITY WITH AT LEAST ONE C CORP MEMBER WITH LESS THAN $1,000.00 OF INCOME

Column B

Column A

Number of

C Corporations

Members

Rhode Island source income of ALL nonresident C Corporation members net of modifications

(attach schedule) ..........................................................................................................................

Rhode Island source income of those nonresident C Corporation members with income of less

than $1,000 net of modifications (attach schedule) ......................................................................

Rhode Island source income of nonresident C Corporation members with income of $1,000 or

more net of modifications. Subtract line 2 from line 1. Enter here and on pg 1, Col A, Line 1a

SCHEDULE B -

CALCULATION FOR AN ENTITY WITH AT LEAST ONE NON-C CORP MEMBER WITH LESS THAN $1,000.00 OF INCOME

Column B

Column A

Number of

Sub S Corps, Individuals, LLCs,

Members

Partnerships and Trusts

Rhode Island source income of ALL nonresident members other than C Corporations net of

modifications (attach schedule) ....................................................................................................

Rhode Island source income of those nonresident members other than C Corporations with in-

come of less than $1,000 net of modifications (attach schedule) .................................................

Rhode Island source income of nonresident members other than C Corporations with income of $1,000 or

more net of modifications. Subtract line 2 from line 1. Enter here and on page 1, Column B, Line 1b

WORKSHEET FOR PAGE 1, LINE 5

Rhode Island nonresident real estate withholding - ONLY include if a breakdown of each shareholder’s with-

holding amount was provided to the RI Division of Taxation at the time of closing - Attach copy of 71.3 form

Rhode Island estimated tax paid by members on their personal return attributable to income on this return (see in-

structions).

Excess Rhode Island withholding tax paid by this entity for members (see instructions)............................................ 5c

Rhode Island credit purchased by a member for use in 2015. Refer to Schedule CR for elgible credits...................

Total. Add lines 5a, 5b, 5c and 5d. Enter here and on page 1, line 5........................................................................

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and

belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Authorized officer signature

Print name

Date

Telephone number

Paid preparer signature

Print name

Date

Telephone number

Paid preparer address

City, town or post office

State

ZIP Code