State of Rhode Island and Providence Plantations
Form BUS-EXT
13111499990101
Business Tax Automatic Extension Request
Name
Federal employer identification number
Address
For the period ending:
MM/DD/YYYY
Address 2
City, town or post office
State
ZIP code
E-mail address
This form must be completed and filed before the date prescribed for payment of the tax.
Part 1: Automatic six-month extension
Form RI-1120POL - Rhode Island Political Organization - Key #77
Form T-72 - Rhode Island Public Service Corporation Gross Earnings - Key #22
Form T-74 - Rhode Island Banking Institution Excise - Key #11
Mail voucher and payment to:
RI Division of Taxation
One Capitol Hill - Suite 9
Providence, RI 02908-5811
Part 2: Amount due with extension
Estimated tax due for the current year.....................................................................................
1
1
Carry forward and estimated payments paid to date...............................................................
2
2
Balance due with extension request. Subtract line 2 from line 1............................................
3
3
Amount paid with extension request........................................................................................
4
4
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, accurate and complete Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge
Authorized officer signature
Print name
Date
Telephone number
Paid preparer signature
Print name
Date
Telephone number
Paid preparer address
City, town or post office
State
ZIP Code
PTIN
May the Division of Taxation contact your preparer? YES
Revised 10/2013