valueassigned=T1incrementedby2024         NACTPRI1040R if items included######### in barcode are changed,######### number,defaultstreet,left="0001"justifyRR,"0"orfor"0"POblankfor"0"Boxblankfor"0""1"blankfor"0"for"1"blankfor"0"checkedfor"1"blankforValidcheckedfor"1"blank"0"checkedlettersfor"1"for"0"checkedfor"1"blankfor"0"R,checkedforblankfor"0"D,checked"1"blankfor"0"L,for"1"G,blankforcheckedfor"1"C,blankNocheckedI,for"1"commas,NoW,checkedfor"1"Nocommas,F,checkedforPcommas,NoandcheckednoNocommas,decimalNnocommas,decimalno decimalnopoint,decimalnopoint,decimalmustpoint,mustpoint,includemustpoint,includemustincludecentsmustincludecentsincludecentscentscents        Edit and Instructions 

                                                                                                                                                                                                                                                                                                                                                       TypeAN            N N                        N AN AN           AN    AN AN N           AN AN AN   AN  N         AN AN   AN                AN AN      N        N              N       N             N             N                A             N                  N                       N                         N                      N                                               N                     N            N                    N                 N

                                                                                                                                                                                                                                                                                                                                                                       2 4 4                        4 7  14           1     20 3  9           14 1  20   3   9         35 21   2                 9  21      1        1              1       1             1             1                1             1                  1                       1                         1                      1                                               12                    12           12                   12                12
                                                                                                                                                                                                                                                                                                                                                       Max Size

                                                                                                                                                                                                                                                                                                                                                                                                                            09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                      DRAFT 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       YES

                                                                                                                                                                                                                                                                                                                                                                       HEADERYES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  SECTION 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            RI-1040 INFORMATION
                                                                                                                                                                                                                                                                                                                                                                             DEMOGRAPHIC INFORMATION
                                                                                                                                                                                                                                                                             Tax Year 2024  Rhode Island Form RI-1040 & 1040H 2D Barcode Layout

                                                                                                                                                                                                                                                                                                                                                       FieldCodeDeveloperandSoftware/formHeaderTaxCodeFormYearVersionPrimaryversionTypePrimaryPrimaryFirstPrimaryMINamePrimarylastSpousesuffixname,SpouseSSNSpouseFirstnoSpouseMIsuffixNameSpouseLastAddress suffixNameCitySSNState orZipTownCity+ 4PrimaryorSpouseTownNewdeceasedofAmended deceasedaddressLegalElectoralElectoralResidenceElectoralSystemSingle specificMarriedPartyContributionMarriedpartyHeadJointspecifiedQualifyingSeparateof HouseholdFederalNetWidow(er)ModifiedModificationsAdjustedRI StandardLineFederalGross5 DeductionIncomeAGI                                                                                                                                      Name 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   1                     2            3                    4                 5
                                                                                                                                                                                                                                                                                                                                               RI Form         Line Ref

                                                                                                                                                                                                                                                                                                                                                                       12345678910111213141516171819202122232425262728293031323334353637
                                                                                                                                                                                                                                                                                                                                                       Field ID
Barcode size and layout requirements                                                                                                                     The barcode should be Normal PDF417 style with no more then 13 columns ( 2 for header, 2 for footer and 9 for data).

No commas, no decimal point, must include cents                      No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents "0" for blank "1" for checked No commas, no decimal point, must include cents "0" for blank "1" for checked  No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents "0" for blank "1" for checked                          left justify, no hyphens                                                                                                                    No commas, no decimal point, must include cents No commas, no decimal point, must include cents                     No commas, no decimal point, must include cents                                   No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents                              "0" for blank "1" for checked

N                                               N                    N                                               N                                               N                                               N                                               N                                               N                                               N                             N                                               N                              N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                                      AN                        N                      AN                        N                     AN                                         N                                               N                                               A                   N                                                                                 N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                                                            N

12                                              2                    12                                              12                                              12                                              12                                              12                                              12                                              1                             12                                              1                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              1                                                      9                         10                     2                         10                    2                                          9                                               9                                               2                   9                                                                                 9                                               9                                               9                                               9                                               9                                               9                                               9                                               9                                               9                                               9                                                                            1

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  09/30/2024

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   RI Schedule I & II

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           RI-1040H Property Tax Relief
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         RI Checkoff Contributions Schedule

Exemption amount                                Number of exemptions Allowable Federal Credit                        Tax Paid Other State                            Other RI Credits                                Total RI Credits                                Recapture of RI Credits                         Checkoff Contributions                          Use Tax Checkbox              RI Sales & Use Tax                              Full-year HC Coverage Checkbox Individual Mandate Penalty                      Schedule W                                      Estimates                                       1040H                                           EIC                                             RI Residential Lead Paint Credit                Other Payments                                  Total Payments and Credit                       Previously Issued Overpayments                  2210 amount                                     Refund amount                                   Carry over to next year                         Division Contact Preparer   Yes                        Preparer SSN, PTIN or EIN Primary license number Primary license issued by Spouse license number Spouse license issued by                   Child & Dependent Care Credit                   AGI from other State                            Name of other state amount of tax paid to other state                                                 Drug Program account                            Olympic Contributions                           Organ Transplant                                Council on the Arts                             Non-Game wildlife                               Childhood Disease Victims Fund                  Military Family Relief Fund                     Behavioral Health                               Total Contributions                             Federal EIC                                                                  legal resident flag    YES

6                                               6                    9a                                              9b                                              9c                                              9d                                              10b                                             11                                                                            12a                                                                            12b                                             14a                                             14b                                             14c                                             14d                                             14e                                             14f                                             14g                                             14h                                             15B                                             17                                              18                                                                                                                                                                                                                                                 20                                              24                                              28                  28                                                                                30                                              31                                              32                                              33                                              34                                              35                                              36                                              37                                              38                                              39
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        1040H A
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  signature area                                         signature area

3839404142434445464748495051525354555657585960616263646566676869707172737475767778798081

"0" for blank "1" for checked "0" for blank "1" for checked "0" for blank "1" for checked "0" for blank "1" for checked No commas, no decimal point, must include cents No commas, no decimal point, must include cents mmddyyyy              mmddyyyy             "0" for blank "1" for checked                                                                        No commas, no decimal point, must include cents No commas, no decimal point, must include cents                                                No commas, no decimal point, must include cents

N                             N                             N                             N                             N                                               N                                               AN                    AN                   N                             N                              N                                       N                                               N

1                             1                             1                             1                             9                                               9                                               8                     8                    1                             2                              2                                       9                                               9                                                                                              9N

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                DRAFT 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                        RI-6238 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 NULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENT

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      THIS SECTION WOULD BE NULL                            THIS SECTION WOULD BE NULL 

Rent Flag  YES                Prior year Current  YES       Over 65  YES                  Household Income  YES         Cash public assistance                          Total Household Income                          Primary date of birth Spouse date of birth Disability switch - YES       Number of persons in household Number of persons in household under 18 Amount of property tax paid                     Amount of rent paid                                                                            Total Credit

1040H B                       1040H C                       1040H D                       1040H E                       1040H 1A                                        1040H 1B                                        1040H 1C              1040H 1D             1040H 1E                      1040H 1F                       1040H 1G                                1040H 2                                         1040H 7                                                                                        RI 6238 7

828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125

                                                    No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents          No commas, no decimal point, must include cents No commas, no decimal point, must include cents         No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents         No commas, no decimal point, must include cents                 mmddyyyy

                                                    N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                                        N                                               N                                                       N                                               N                                               N                                                       N                                                               AN

                                                    12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                                       12                                              12                                                      12                                              12                                              12                                                      12                                                              8

09/30/2024

DRAFT 

NULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORFORRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENT
                          Schedule M - Modifications

                                                    Income from obligations of the US Gov           RI fiduciary adjustment                         Elective deduction for new R&D                  Railroad Retirement benefits                    Qualifying investment in venture capital        Family Education Accounts                       Tuition Savings Program                         Exemptions for writers, composers and artists   Bonus depreciation                              Section 179                                     Modifications for Jobs Growth Act               Modifications for Tax Incentives for Capital Investments Modifications for Tax Incentives for employers  Historic Tax Credit or Motion Picture Production Income Active duty military                            Scituate Medical Savings Account                Insurance benefits for dependents and domestic partners Modification for Organ Transplantation                          Mod SS income Primary DOB

                                                    SchM 1a                                         SchM 1b                                         SchM 1c                                         SchM 1d                                         SchM 1e                                         SchM 1f                                         SchM 1g                                         SchM 1h                                         SchM 1i                                         SchM 1j                                         SchM 1k                                         SchM 1l                                                  SchM 1m                                         SchM 1n                                                 SchM 1o                                         SchM 1p                                         SchM 1q                                                 SchM 1r                                                         SchM 1s

126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171

mmddyyyy                                            No commas, no decimal point, must include cents mmddyyyy                       mmddyyyy                                         No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents      No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents                        No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents                         No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents                                                   No commas, no decimal point, must include cents                                                   No commas, no decimal point, must include cents                                       No commas, no decimal point, must include cents                          No commas, no decimal point, must include cents No commas, no decimal point, must include cents                          No commas, no decimal point, must include cents                                                No commas, no decimal point, must include cents

AN                                                  N                                               AN                             AN                                               N                                               N                                               N                                                    N                                               N                                               N                                               N                                               N                                               N                                                                      N                                               N                                               N                                               N                                                                       N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               AN                        AN                      N                                               AN                        AN                      N                                                                                     N                                               AN                       N                                               N                                               AN                       N                                                                                              N                                              AN

8                                                   12                                              8                              8                                                12                                              12                                              12                                                   12                                              12                                              12                                              12                                              12                                              12                                                                     12                                              12                                              12                                              12                                                                      12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              10                        10                      9                                               10                        10                      9                                                                                     12                                              2                        12                                              12                                              2                        12                                                                                             12                                             2

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                DRAFT 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                NULLNULLNULLNULLNULLFORFORFORFORFORRESIDENTRESIDENTRESIDENTRESIDENTRESIDENT
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Schedule CR - RI Credits

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Schedule MU - Tax Paid to Other States

Mod SS income Spouse DOB                            Mod Social Security income                      Mod Pension income Primary DOB Mod Pension income Spouse DOB                    Mod Pension income                              CASH PTE Deduction                              Modification for receiving military service pensions Income from obligations of any other state      RI fiduciary adjustment                         Recapture of Family Education Account           Bonus depreciation                              Recapture of Tuition Saving Program             Recapture of Historic Tax Credit                                       Recapture of Scituate Medical Savings           Pass-through Entity Tax Election                Unemployment Compensation                       Paychck Protection Program                                              RI-0715                                         RI-2276                                         RI-286B                                         RI-5442                                         RI-6754                                         RI-7253                                         RI-8201                                         RI-9283                                         Total Credits                                   Recapture Credit 1 Number Recapture Credit 1 Name Recapture Credit 1 Amount                       Recapture Credit 2 Number Recapture Credit 2 Name Recapture Credit 2 Amount                                                             Total AGI other state                           Tax Due other state name Tax Due other state paid                        Total AGI other state                           Tax Due other state name Tax Due other state paid                                                                       Total AGI other state                          Tax Due other state name

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  MU 2                                            MU 6                     MU 6                                            MU 9                                            MU 13                    MU 13                                                                                          MU 16                                          MU 20
SchM 1s                                             SchM 1s                                         SchM 1t                        SchM 1t                                          SchM 1t                                         SchM 1u                                         SchM 1v                                              SchM 2a                                         SchM 2b                                         SchM 2c                                         SchM 2d                                         SchM 2e                                         SchM 2f                                                                SchM 2g                                         SchM 2h                                         SchM 2i                                         SchM 2j                                                                 Sch CR 1                                        Sch CR 2                                        Sch CR 3                                        Sch CR 4                                        Sch CR 5                                        Sch CR 6                                        Sch CR 7                                        Sch CR 8                                        Sch CR 9                                        Sch CR 10                 Sch CR 10               Sch CR 10                                       Sch CR 11                 Sch CR 11               Sch CR 11

172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216

No commas, no decimal point, must include cents No commas, no decimal point, must include cents                          No commas, no decimal point, must include cents No commas, no decimal point, must include cents                                            No commas, no decimal point, must include cents No commas, no decimal point, must include cents No commas, no decimal point, must include cents         "0" for blank "1" for checked     "0" for blank "1" for checked                         "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)                                                No commas, no decimal point, must include cents

N                                               N                                               AN                       N                                               N                                                                                                                                                                                                                                                  N                                 N                                                     N                                                                                                                                                                                N                                                                                                                                                                                N                                                                                                                N               N                                               N                             A                                                                                  N               N                                               N                             A                                                                                  N                                                            N

12                                              12                                              2                        12                                              12                                                                                         9N                                              9N                                              9N                                                      1                                 1                                                     1                             1A                                                                                 9N              9N                                              1                             1A                                                                                 9N              9N                                              1                             1A                                                                                 9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9                                                            9

                                                                                                                                                                                                                                                                    09/30/2024

                                                                                                                                                                                                                                                                    DRAFT 

                                                                                                                                                                                                                                                                                                                                                                                                                    RI -2210

                                                                                                                                                                                                                                                                    NULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLNULLScheduleFORFORFORFORFORFORFORFORFORFORFORFORFORURESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENTRESIDENT- Use Tax
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Schedule W - Withholding

                                                                                                                                                                                                                         Schedule NR-MU - Taxes Paid to Other States

Tax Due other state paid                        Total AGI other state                           Tax Due other state name Tax Due other state paid                        Total Credit                                                                               Option 1 use tax due                            Option 2 use tax due lookup                     Option 2 use tax due                                    Taxpayer is a Farmer or Fisherman Taxpayer is annualizing                               Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID                                              RI Withholding

MU 20                                           MU 23                                           MU 27                    MU 27                                           MU 30                                                                                      Sch U 4                                         Sch U 6                                         Sch U 8                                                                                                                                         Sch W A1                      Sch W B1                                                                           Sch W D1        Sch W E1                                        Sch W A2                      Sch W B2                                                                           Sch W D2        Sch W E2                                        Sch W A3                      Sch W B3                                                                           Sch W D3        Sch W E3                                        Sch W A4                      Sch W B4                                                                           Sch W D4        Sch W E4                                        Sch W A5                      Sch W B5                                                                           Sch W D5                                                     Sch W E5

217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259

"0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents "0" for blank "1" for checked Values "S","B","D","G","I","M","O","R","P","K", "E", "N", "W"; blank if not marked ######### (9)   No commas, no decimal point, must include cents                                                              0 for blank "1" for checked 0 for blank "1" for checked                   ######### (9)         mmddyyyy

N                             A                                                                                  N               N                                               N                             A                                                                                  N               N                                               N                             A                                                                                  N               N                                               N                             A                                                                                  N               N                                               N                             A                                                                                  N               N                                               N                                                                                                                                                                                N                                                                                                                                                                                N                                                                                                                                N                                               N                             A                                                                                  N               N                                               N                             A                                                                                  N               N                                               N                                                            N                           N                           AN                N                     AN

1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1A                                                                                 9N              9N                                              1                             1A                                                                                 9N              9N                                              1                             1A                                                                                 9N              9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               5                                                            1                           1                           40                9                     8

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    DRAFT 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Schedule E - Exemption Schedule

Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Spouse Checkbox               1099 Checkbox                                                                      Employer Fed ID RI Withholding                                  Total Number of W2s and 1099s                                Taxpayer Checkbox           Spouse Checkbox             Name of Dependent SSN                   Date of Birth

Sch W A6                      Sch W B6                                                                           Sch W D6        Sch W E6                                        Sch W A7                      Sch W B7                                                                           Sch W D7        Sch W E7                                        Sch W A8                      Sch W B8                                                                           Sch W D8        Sch W E8                                        Sch W A9                      Sch W B9                                                                           Sch W D9        Sch W E9                                        Sch W A10                     Sch W B10                                                                          Sch W D10       Sch W E10                                       Sch W A11                     Sch W B11                                                                          Sch W D11       Sch W E11                                       Sch W A12                     Sch W B12                                                                          Sch W D12       Sch W E12                                       Sch W A13                     Sch W B13                                                                          Sch W D13       Sch W E13                                       Sch W A14                     Sch W B14                                                                          Sch W D14       Sch W E14                                       Sch W A15                     Sch W B15                                                                          Sch W D15       Sch W E15                                       Sch W 17                                                     Sch E A1                    Sch E B1                    Sch E 2a          Sch E 2a              Sch E 2a

260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305

                               ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                     ######### (9) mmddyyyy                                        ######### (9)

AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                N             AN            AN           AN                   N

12           40                9             8             12           40                9             8             12           40                9             8             12           40                9             8             12           40                9             8             12           40                9             8             12           40                9             8             12           40                9             8             12           40                9             8             12           40                9             8             12           40                9             8             12           40                   9

                                                                                                                                                                                                                                                         09/30/2024

                                                                                                                                                                                                                DRAFT 

Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent SSN           Date of Birth Relationship Name of Dependent    SSN

Sch E 2a     Sch E 2b          Sch E 2b      Sch E 2b      Sch E 2b     Sch E 2c          Sch E 2c      Sch E 2c      Sch E 2c     Sch E 2d          Sch E 2d      Sch E 2d      Sch E 2d     Sch E 2e          Sch E 2e      Sch E 2e      Sch E 2e     Sch E 2f          Sch E 2f      Sch E 2f      Sch E 2f     Sch E 2g          Sch E 2g      Sch E 2g      Sch E 2g     Sch E 2h          Sch E 2h      Sch E 2h      Sch E 2h     Sch E 2i          Sch E 2i      Sch E 2i      Sch E 2i     Sch E 2j          Sch E 2j      Sch E 2j      Sch E 2j     Sch E 2k          Sch E 2k      Sch E 2k      Sch E 2k     Sch E 2l          Sch E 2l      Sch E 2l      Sch E 2l     Sch E 2m             Sch E 2m

306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352

mmddyyyy                                                                                                          ######### (9) 0 for blank "1" for checked                       Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked                                    ######### (9) 0 for blank "1" for checked                       Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked                                    ######### (9) 0 for blank "1" for checked                       Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked                                                                                     Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked

AN            AN                                                                                AN                N             N                           AN                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                AN                N             N                           AN                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                AN                N             N                           AN                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                                                                                                        N

8             12                                                                                35                9             1                           8                     2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    3                35                9             1                           8                     2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    3                35                9             1                           8                     2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                                                                                                        2

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     DRAFT 

                                                IND-HEALTH - Individual Health Care Mandate Form
Date of Birth Relationship                                                                      Name of Dependent SSN           Under 18 Years of Age       HSRI Exemption Number January                                                                              February                                                                             March                                                                                April                                                                                May                                                                                  June                                                                                 July                                                                                 August                                                                               September                                                                            October                                                                              November                                                                             December                                                                             Number of months Name of Dependent SSN           Under 18 Years of Age       HSRI Exemption Number January                                                                              February                                                                             March                                                                                April                                                                                May                                                                                  June                                                                                 July                                                                                 August                                                                               September                                                                            October                                                                              November                                                                             December                                                                             Number of months Name of Dependent SSN           Under 18 Years of Age       HSRI Exemption Number January                                                                              February                                                                             March                                                                                April                                                                                May                                                                                                                                                                      June

Sch E 2m      Sch E 2m                                                                          IND-H 1           IND-H 1       IND-H 1                     IND-H 1               IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1                                                                              IND-H 1          IND-H 2           IND-H 2       IND-H 2                     IND-H 2               IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2                                                                              IND-H 2          IND-H 3           IND-H 3       IND-H 3                     IND-H 3               IND-H 3                                                                              IND-H 3                                                                              IND-H 3                                                                              IND-H 3                                                                              IND-H 3                                                                                                                                                                  IND-H 3

353354355356357358359360361362363364365366367368369370371372373374375376377378379380381382383384385386387388389390391392393394395396397398

Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked                                    ######### (9) 0 for blank "1" for checked                       Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked                                    ######### (9) 0 for blank "1" for checked                       Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI"; blank if not marked                                                                                                                         value = "*EOD*"

N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                AN                N             N                           AN                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                AN                N             N                           AN                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                                                                                    N                N                                                                    N                                 AN

2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    3                35                9             1                           8                     2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    3                35                9             1                           8                     2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    2                                                                                    3                3                                                                    3                                 5

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                DRAFT 

July                                                                                 August                                                                               September                                                                            October                                                                              November                                                                             December                                                                             Number of months Name of Dependent SSN           Under 18 Years of Age       HSRI Exemption Number January                                                                              February                                                                             March                                                                                April                                                                                May                                                                                  June                                                                                 July                                                                                 August                                                                               September                                                                            October                                                                              November                                                                             December                                                                             Number of months Name of Dependent SSN           Under 18 Years of Age       HSRI Exemption Number January                                                                              February                                                                             March                                                                                April                                                                                May                                                                                  June                                                                                 July                                                                                 August                                                                               September                                                                            October                                                                              November                                                                             December                                                                             Number of months Number of adult months no coverage                                   Number of child months no coverage

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Trailer
IND-H 3                                                                              IND-H 3                                                                              IND-H 3                                                                              IND-H 3                                                                              IND-H 3                                                                              IND-H 3                                                                              IND-H 3          IND-H 4           IND-H 4       IND-H 4                     IND-H 4               IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4                                                                              IND-H 4          IND-H 5           IND-H 5       IND-H 5                     IND-H 5               IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5                                                                              IND-H 5          Adult Total                                                          Child Total

399400401402403404405406407408409410411412413414415416417418419420421422423424425426427428429430431432433434435436437438439440441442