State of Rhode Island and Providence Plantations 
Form PW - COVID 19 
Coronavirus Hardship Penalty Waiver Request

Name                                                                            Federal employer identification/social security number

Address                                                                         For the period ending:

Address 2                                                                       Phone number

City, town or post office                             State ZIP code            E-mail address

If you received an interest and penalty assessment as a result of a Coronavirus Disease 2019 (COVID-19) related hardship, complete this penalty 
waiver request form and mail it, along with a copy of the assessment(s) and payment of any tax and interest, to the RI Division of Taxation.
Select the tax type(s) for which you received an assessment and the amount for which you are requesting a waiver.  Check all that apply.

                         Tax Type                                  Penalty
Withholding Tax

Sales Tax

Meals and Beverage Tax

Hotel tax

Personal Income Tax

Corporate Income Tax

Other: Enter type _______________________

Total for all tax types:

Please provide an explanation for this request as it  
relates to the Coronavirus Disease 2019 (COVID-19): 
(attach statement if additional space is needed)

Send your completed Coronavirus Hardship Penalty Waiver     RI Division of Taxation 
Request form along with a copy of any assessments and       One Capitol Hill 
payment of any tax and interest to:                         Providence, RI 02908 
                                                            Attn: COVID-19 Hardship
Under penalties of perjury, I declare that I have examined this request form and accompanying statements, and to the best of my knowledge and belief it 
is true, accurate and complete.  I further certify that I qualify for the relief requested and acknowledge that I may be subject to civil and criminal penalties 
imposed by law, including, but not limited to, R.I. Gen. Laws § 44-1-37(a), if the information contained in this form is not true and accurate.  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