Tax Payer Status Affidavit / Identity Form - Department Of Business Regulation (Page 2 of 2) in pdf

Tax Payer Status Affidavit / Identity Form - Department Of Business Regulation Page 2

State of Rhode Island and Providence Plantations

DEPARTMENT OF BUSINESS REGULATION

BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS

1511 Pontiac Avenue, Bldg. 68-2

Cranston, Rhode Island 02920

Tel: (401) 462-9592 Fax: (401) 462-9532 Website:

TAX PAYER STATUS AFFIDAVIT / IDENTITY FORM

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.

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)

________________________________________________

Date

Tax Payer Status Affidavit / Identity Form - Department Of Business Regulation Page 2