Form Ri 433 A - Collection Information Statement For Wage Earners And Self-Employed Individuals - Rhode Island Division Of Taxation

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RI 433 A
COLLECTION INFORMATION STATEMENT FOR WAGE EARNERS
AND SELF-EMPLOYED INDIVIDUALS
Rhode Island Division
of Taxation
Complete all entry spaces with the most current data available
(Revised 12/01)
Write "N/A" (not applicable) in spaces that do not apply.
Section 1
Full Name(s)
Home Telephone (
)
Best Time To Call:
Personal
Street Address
Info
Marital Status:
City________________________________ State_________Zip____________
( ) Married ( ) Separated
( ) Single
Your Social Security Number
____/_____/_____
Date of Birth
____/____/______
Spouse's Social Security Number
____/_____/_____
Spouse's DOB ____/____/______
( ) Own Home ( ) Rent ( ) Other (specify, i.e. share rent, live with relative)
List the dependents you can claim on your tax return: (Attach sheet if more space is needed)
First Name Relationship Age
Does This Person
First Name Relationship Age
Does This Person
Live With You
Live With You
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
( ) No ( ) Yes
Adjusted Gross Income from Current Year Filing of Federal Personal Income Tax Return:
$
Are you or your spouse self-employed or a partner operating a business?
Section 2
Sole Proprietor ( )
Partnership ( )
Name of Business
Employer I.D. No.
Your
Business
Street Address
Business Telephone
(
) ______________
Info
City __________________________State _____ Zip ___________
Do you have employees? ( ) No ( ) Yes
Do you have accounts receivable?
( ) No ( ) Yes
Employer
Spouse's Employer
Section 3
Street Address
Street Address
City ___________________State _____ Zip _________
City ___________________State _____ Zip _________
Employ-
ment Info
Work Telephone No.
(
)______ (
)___________
Work Telephone No. (
)______________
May we contact you at work? ( ) No ( ) Yes
May we contact you at work? ( ) No ( ) Yes
Occupation __________________________________
Occupation____________________________________
Do you receive income from sources other than your own business or employer? (Check all that apply)
Section 4
( ) Pension
( ) Social Security
( ) Other (specify, i.e. child support, alimony, rental)_________________
Other
Income
Info

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