Affidavit For Owner/employee Not On Payroll Form (Page 2 of 2) in pdf

Affidavit For Owner/employee Not On Payroll Form Page 2

STATE OF _____________________

COUNTY OF ____________________

In _______________, on the _____________ day of ____________, 20___, before me, a Notary Public in and for the above state

and county, personally appeared _____________________________________________, known to me or proved to be the

person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she

executed said instrument for the purposes therein contained as his or her free and voluntary act and deed.

Type of ID Produced: _________________________

Affiant __ is __ is not personally known to me.

_______________________________

NOTARY PUBLIC

My Commission

Expires: ________

(SEAL)

Note: If your group is unable to provide a formal payroll document or a RI Quarterly Tax and Wage Report, please also

attach ONE of the following:

Name of Company as filed and viewable in the Secretary of State website

Copy of license or permit as a RI business

Copy of RI Sales Tax or Litter Permit

Copy of RI Business Application and Registration form submitted to RI Division of Taxation

Copy of a contract that verifies income as a Business

Rhode Island Bank Account in the Company Name

Rhode Island Phone Bill/Utility Bill in the Company Name

And other documentation that verifies that you are a RI business

SGU

Page 2 of 2

Last Updated 3/11/2009

Affidavit For Owner/employee Not On Payroll Form Page 2