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Rhode Island - Mandatory Addendum Form To License Application - Tax Payer Status Affidavit / Identity Verification

Rhode Island Department of Health

3 Capitol Hill, Providence RI, 02908-5097

MANDATORY ADDENDUM TO LICENSE APPLICATION

Tax Payer Status Affidavit / Identity Verification

All persons applying or renewing any license, registration, permit or other

authority (herein after called “licensee”) to conduct a business or occupation in

the state of Rhode Island are required to file all applicable tax returns and pay all

taxes owed to the state prior to receiving a license as mandated by state law

(RIGL 5-76) except as noted below.

In order to verify that the state is not owed taxes, licensees are required to

provide their Social Security Number, or Federal Tax Identification Number (for

businesses) as appropriate. These numbers will be transmitted to the Division of

Taxation to verify tax status prior to the issuance of a license.

Licensee Declaration

□

I hereby declare, under penalty of perjury, that I have filed all required

state tax returns and have paid all taxes owed.

□

I have entered a written installment agreement to pay delinquent taxes

that is satisfactory to the Tax Administrator.

□

I am currently pursuing administrative review of taxes owed to the state.

□

I am in federal bankruptcy. (Case # ___________________________)

□

I am in state receivership. (Case # ___________________________)

□

I have been discharged from Bankruptcy.

(Case # ___________________________)

Type of Professional/Business License for which you are applying

___________________________

____________________________

Full Name (Please Print or Type)

Social Security Number (or FEIN for Business)

____________________________________

______________________________________

Signature

Phone Number (including area code if not 401)

___________________________________

____________________________________

Date

Name of Business (If Applicable)

This form must be completed, signed and attached to your license application for processing.

Rhode Island - Mandatory Addendum Form To License Application - Tax Payer Status Affidavit / Identity Verification