Form Ri 433 B-Collection Information Statement Businesses
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5RI 433 B
COLLECTION INFORMATION STATEMENT BUSINESSES
Rhode Island Division
of Taxation
Complete all entry spaces with the most current data available
Write "N/A" (not applicable) in spaces that do not apply.
(Revised 12/01)
Section 1
Business Name
Contact Name________________________
Title ________________________________
Business
Business St. Address
Business Telephone (
)_______________
Information
Extension
City________________________________ State_________Zip____________ Best Time To Call______________________
Business Telephone Number (
) _________________
Contact Name
_______________
Employer Identification Number ___________________
Contact Home Telephone ______________
Best Time To Call_____________________
Type of Entity (Check Appropriate Box)
( ) Partnership
( ) Corporation
( ) Other______________
Type Business __________________________________________
PERSON RESPONSIBLE FOR DEPOSITING PAYROLL TAXES
Section 2
Full Name
Social Security Number _____/___/______
Business
Home St. Address
Home Telephone No. (
) ______________
Personnel
City___________________________ State_______Zip__________
Title ________________________________
and
Contacts
PERSON RESPONSIBLE FOR REMITTANCE OF SALES TAXES
Full Name
Social Security Number _____/___/______
Home St. Address
Home Telephone No. (
) ______________
City___________________________ State_______Zip__________
Title ________________________________
PARTNERS, OFFICERS, ETC.
Full Name
Social Security Number _____/___/______
Home St. Address
Home Telephone No. (
) ______________
City___________________________ State_______Zip__________
Title ________________________________
PARTNERS, OFFICERS, ETC.
Full Name
Social Security Number _____/___/______
Home St. Address
Home Telephone No. (
) ______________
City___________________________ State_______Zip__________
Title ________________________________
PARTNERS, OFFICERS, ETC.
Full Name
Social Security Number _____/___/______
Home St. Address
Home Telephone No. (
) ______________
City___________________________ State_______Zip__________
Title ________________________________
PARTNERS, OFFICERS, ETC.
Full Name
Social Security Number _____/___/______
Home St. Address
Home Telephone No. (
) ______________
City___________________________ State_______Zip__________
Title ________________________________
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