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MOUNT DUE AND PAID SIGNATURE OF OWNER, PARTNER OR AUTHORIZED AGENT TITLE , , . DATE STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DIVISION OF TAXATION - DEPT#200 - PO BOX 9703 - PROVIDENCE, RI 02940-9703 WITHHOLDING TAX RETURN QUARTERLY/MONTHLY TEMPORARY Use in lieu of preprinted coupon booklet WTQM NAME ADDRESS FEDERAL IDENTIFICATION NUMBER CITY, STATE, ZIP CODE RETURN FOR QUARTER/MONTHLY PERIOD ENDING I HEREBY CERTIFY THAT THIS RETURN TO THE BEST OF MY KNOWLEDGE AND BELIEF IS.

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