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E TITLE DATE FEDERAL IDENTIFICATION NUMBER RETURN FOR QUARTER ENDING FORM T-204Q REVD 7/2011 I HEREBY CERTIFY THAT THIS RETURN, TO THE BEST OF MY KNOWLEDGE AND BELIEF, IS A TRUE, CORRECT AND COMPLETE RETURN. SIGNATURE OF OWNER, PARTNER OR AUTHORIZED AGENT NET SALES AND USE TAX DUE AND PAID $ SALES & USE TAX RETURN STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DIVISION OF TAXATION - DEPT#300 - PO BOX 9706 - PROVIDENCE, RI 02940-9706 QUARTERLY NAME ADDRESS STQ CITY, STATE & ZIP COD.

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