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RHODE ISLAND DIVISION OF TAXATION INSTALLMENT AGREEMENT GENERAL INFORMATION The R. I. Division of Taxation may afford you the opportunity to enter into an installment agreement should you be able to present facts that you are unable to pay the balance in full at this time. Approval for such an agreement will be based upon the information that is outlined below and must be submitted to this office. All requests for an agreement along with any payments must be forwarded to COLLECTION SECTION ONE CAPITOL HILL - SUITE 10 PROVIDENCE RI 02908-5812 The information will be reviewed by the Compliance and Collection Section for final approval. Within thirty days of receipt of your proposed agreement including all required information you will be notified in writing of the approval or denial. The agreement will be revoked for failure to meet the agreed upon monthly payment and/or failure to file and pay all future income tax returns on a timely basis. RHODE ISLAND DIVISION OF TAXATION INSTALLMENT AGREEMENT GENERAL INFORMATION The R* I. Division of Taxation may afford you the opportunity to enter into an installment agreement should you be able to present facts that you are unable to pay the balance in full at this time. Approval for such an agreement will be based upon the information that is outlined below and must be submitted to this office. All requests for an agreement along with any payments must be forwarded to COLLECTION SECTION ONE CAPITOL HILL - SUITE 10 PROVIDENCE RI 02908-5812 The information will be reviewed by the Compliance and Collection Section for final approval* Within thirty days of receipt of your proposed agreement including all required information you will be notified in writing of the approval or denial* The agreement will be revoked for failure to meet the agreed upon monthly payment and/or failure to file and pay all future income tax returns on a timely basis. In the absence of an approved agreement or default of such agreement collection procedures will be reinstituted which may result in levy of assets wages reblock license/registration or other appropriate legal action* Taxpayer Name s as shown on tax return s Social Security Number s Street Address Home Telephone Number City State Zip Code Business Telephone Number Balance Owed plus any accrued interest and penalties Proposed Monthly Payment NOTE 1ST PAYMENT MUST ACCOMPANY THIS FORM Please circle the date you choose to make your payment each month 15th Day 30th Day Name and Address of Employer Checking Bank Account Signature of Taxpayer Signature of Spouse OFFICE USE ONLY FILINGS Y N AGI The law authorizes the filing of State Tax Liens. Failure to pay the amount indicated in full will result in the filing of a Tax Lien* SEE OTHER SIDE INCOME/EXPENSE STATEMENT Column A MONTHLY NET INCOME Wages/ Salaries Other Income List Sources MONTHLY EXPENSES Amount Rent Utilities Food Medical Insurance Clothing 8 Other List type 14 Enter Line 34 Total monthly 15 intstallment payments 17 TOTAL MONTHLY EXPENSE TOTAL MONTHLY INCOME Line 17 Column A Total Monthly Income Less Column B Total Monthly Expenditures BALANCE SHEET ASSETS Cash Savings Retirement Accounts Investment Stock Bonds TOTAL CURRENT ASSETS Vehicle Make Year Real Estate Address TOTAL ASSETS LIABILITIES Mortgage Auto Loans Personal Loans Fed* Taxes Due State Taxes Due Credit Card s 28 Other List 34 TOTAL LIABILITIES Monthly Pmt true and correct to the best of my knowledge and belief* Signature Date..

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