Form Application For Professional Fundraiser/mandatory Addendum Form To License Application Page 3
ADVERTISEMENT
1
2
3State of Rhode Island and Providence Plantations
DEPARTMENT OF BUSINESS REGULATION
SECURITIES DIVISION
CHARITABLE ORGANIZATION SECTION
1511 Pontiac Avenue, Bldg. 69-1
Cranston, Rhode Island 02920
EXHIBIT 1
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 §5-76-2) 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.
PLEASE CHECK ONE BOX ONLY, EVEN IF YOU HAVE NEVER BEEN EMPLOYED IN RHODE ISLAND.
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)
NOTE: This form must be completed, signed and attached electronically to your application in order for us
to begin processing. Please call the Department with any questions.
Page 3 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal