Form Tx-16 - Claim For Refund Of Temporary Disability Insurance Tax
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2TX-16 (Rev 10/24/2008)
STATE OF RHODE ISLAND
DIVISION OF TAXATION - EMPLOYER TAX SECTION
1 Capitol Hill - Suite 36
Providence, Rhode Island 02908
(401) 574-8700 (Option 2)
or
CLAIM FOR REFUND OF TEMPORARY DISABILITY INSURANCE TAX
IMPORTANT - Please read instructions before completing
1. Enter your Name, Social Security Number, and Address.
YOUR NAME (First, Middle Initial and Last)
SOCIAL SECURITY NUMBER
-
-
NO. AND STREET
CITY
STATE
ZIP CODE
2. Enter the calendar year for which a refund is being claimed, filing date, your signature , and telephone number.
I hereby apply for a refund of taxes paid in excess during the calendar year _________ to the
R.I. Temporary Disability Insurance Fund. I certify that the facts presented including the attached
W-2, are true to the best of my knowledge and belief.
Date:
Signature:
Telephone :
3. IMPORTANT - ATTACH A COPY OF FEDERAL FORM W-2 FOR EACH EMPLOYER LISTED
COMPANY TELEPHONE NUMBER:
COMPANY TELEPHONE NUMBER:
FIRM NAME OF
FIRM NAME OF
EMPLOYER
EMPLOYER
STREET & NUMBER
STREET & NUMBER
CITY STATE & ZIP
CITY STATE & ZIP
WAGE
$
-
WAGE
$
-
COMPANY TELEPHONE NUMBER:
COMPANY TELEPHONE NUMBER:
FIRM NAME OF
FIRM NAME OF
EMPLOYER
EMPLOYER
STREET & NUMBER
STREET & NUMBER
CITY STATE & ZIP
CITY STATE & ZIP
WAGE
$
-
WAGE
$
-
COMPANY TELEPHONE NUMBER:
COMPANY TELEPHONE NUMBER:
FIRM NAME OF
FIRM NAME OF
EMPLOYER
EMPLOYER
STREET & NUMBER
STREET & NUMBER
CITY STATE & ZIP
CITY STATE & ZIP
WAGE
$
-
WAGE
$
-
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