Looking for a Rhode Island Legal Forms And Templates? Download it for free!

Certificate Of Authorization Initial Application - State Of Rhode Island Board Of Registration For Professional Engineers Page 4

Tax Payer Status Affidavit / Identity Verification

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

(hereinafter 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 and Federal Tax Identification Number as appropriate.

These

numbers will be transmitted to the Division of Taxation to verify tax status prior to the

issuance of a license. This declaration must be made prior to the issuance of a license.

Please return this affidavit along with your license application to: Rhode Island Department of

Business Regulation, State Board of Registration for professional Engineers, 1511 Pontiac

Avenue, Building 68-2, Cranston, RI 02920.

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 License for which you are applying

___________________________________

_____________________________________

Full Name (Please Print or Type)

Social Security Number

(or FEIN if appropriate)

___________________________________

______________________________________

Signature

Phone Number

(including area code if not 401)

Date_______________________________

3/12

Certificate Of Authorization Initial Application - State Of Rhode Island Board Of Registration For Professional Engineers Page 4