Edit and Instructions                        value =T1               assigned by NACTP incremented if items included in barcode are changed, default ="0001"                        2023     RI1040R                                                                             #########                                                              #########  number, street, RR, or PO Box                    left justify                                 "0" for blank "1" for checked "0" for blank "1" for checked "0" for blank "1" for checked "0" for blank "1" for checked                                       "0" for blank "1" for checked                          "0" for blank "1" for checked Valid letters R, D, L, G, C, I, W, F, P and N "0" for blank "1" for checked "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 No commas, no decimal point, must include cents No commas, no decimal point, must include cents                                                No commas, no decimal point, must include cents

                                                                                                                                                                                                                                                                                                                                                       Type                                              AN                      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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             YES

                                                                                                                                                                                                                                                                                                                                                                                          HEADER SECTION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 YES
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    RI-1040 INFORMATION
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         DEMOGRAPHIC INFORMATION
                                                                                                                                                                                                                                                                             Tax Year 2023  Rhode Island Form RI-1040 & 1040H 2D Barcode Layout

                                                                                                                                                                                                                                                                                                                                                       Field Name                                        Code and Header Version Developer Code    Software/form version                                                                        Tax Year Form Type Primary First Name Primary MI Primary last name, no suffix Primary suffix Primary SSN Spouse First Name Spouse MI Spouse Last Name Spouse suffix Spouse SSN Address                       City or Town State Zip + 4      City or Town of Legal Residence Primary deceased              Spouse deceased               New address                   Amended                               Electoral System Contribution                               Electoral specific party                               Electoral Party specified                     Single                        Married Joint                 Married Separate              Head of Household             Qualifying Widow(er)                             Federal Adjusted Gross Income                   Net Modifications                               Modified Federal AGI                            RI Standard Deduction                                                                          Line 5 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       1                                               2                                               3                                               4                                                                                              5
                                                                                                                                                                                                                                                                                                                                               RI Form                            Line Ref

                                                                                                                                                                                                                                                                                                                                                                                                         1                       2                 3                                                                                            4        5         6                  7          8                            9              10          11                12        13               14            15         16                            17           18    19           20                              21                            22                            23                            24                                                                  25                                                     26                            27                                            28                            29                            30                            31                            32                                               33                                              34                                              35                                              36                                                                                             37
                                                                                                                                                                                                                                                                                                                                                               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                             "0" for blank "1" for checked                              "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                                                                           1                                                          1

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   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                     Total Contributions                             Federal EIC                                                                 legal resident flag    YES                                 Rent 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
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       1040H A                                                    1040H B
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  signature area                                         signature area

38                                              39                   40                                              41                                              42                                              43                                              44                                              45                                              46                            47                                              48                             49                                              50                                              51                                              52                                              53                                              54                                              55                                              56                                              57                                              58                                              59                                              60                                              61                                                     62                        63                     64                        65                    66                                         67                                              68                                              69                  70                                                                                71                                              72                                              73                                              74                                              75                                              76                                              77                                              78                                              79                                                                          80                                                         81

"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                                               AN                    AN                   N                             N                              N                                       N                                               N

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

                                                                                                                                                                                                                                                                                                                                                                                                                                          RI-6238 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT                            NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT                  NULL FOR RESIDENT

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        THIS SECTION WOULD BE NULL                                                                                                                                                                                                                                                                                                                                                                                           THIS SECTION WOULD BE NULL 

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 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

82                            83                            84                            85                                              86                                              87                    88                   89                            90                             91                                      92                                              93                                                                                             94                                                                        95                96                97                98                99                100               101               102               103               104               105               106               107               108               109               110               111               112               113               114               115                                          116               117               118               119               120               121               122               123               124                                                 125

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  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                                          mmddyyyy

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

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

NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT                  NULL FOR RESIDENT
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        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                         Mod SS income Spouse 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                                           SchM 1s

126               127               128               129               130               131               132               133               134               135               136               137               138               139               140               141               142               143               144               145               146               147               148               149               150                                                 151                           152                                             153                                             154                                             155                                             156                                             157                                             158                                             159                                             160                                             161                                             162                                             163                                                      164                                             165                                                     166                                             167                                             168                                                     169                                             170                                               171

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 No commas, no decimal point, must include cents

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 N

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 12

NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT
Schedule CR - RI Credits

Schedule MU - Tax Paid to Other States

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 Tax Due other state paid

MU 2 MU 6 MU 6 MU 9 MU 13 MU 13 MU 16 MU 20 MU 20
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

172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216

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                              "0" for blank "1" for checked

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

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                                                                            1

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      RI -2210

                                                                                                                                                                                                                    NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT NULL FOR RESIDENT                     Schedule U - Use Tax
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Schedule W - Withholding

                                                                                                                                                                         Schedule NR-MU - Taxes Paid to Other States

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                                                               Spouse Checkbox

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                                                                     Sch W A6

217                                             218                      219                                             220                                                                                        221               222               223               224               225               226               227               228               229               230               231               232               233                                                       234                                             235                                             236                                                     237                               238                                                   239                           240                                                                                241             242                                             243                           244                                                                                245             246                                             247                           248                                                                                249             250                                             251                           252                                                                                253             254                                             255                           256                                                                                257             258                                                                          259

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

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                        AN

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                         12

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Schedule E - Exemption Schedule

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             Relationship

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                  Sch E 2a

260                                                                                261             262                                             263                           264                                                                                265             266                                             267                           268                                                                                269             270                                             271                           272                                                                                273             274                                             275                           276                                                                                277             278                                             279                           280                                                                                281             282                                             283                           284                                                                                285             286                                             287                           288                                                                                289             290                                             291                           292                                                                                293             294                                             295                           296                                                                                297             298                                             299                                                          300                         301                         302               303                   304                       305

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

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                     AN

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                     8

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                   Date of Birth

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              Sch E 2m

306               307           308           309          310               311           312           313          314               315           316           317          318               319           320           321          322               323           324           325          326               327           328           329          330               331           332           333          334               335           336           337          338               339           340           341          342               343           344           345          346               347           348           349          350               351                   352

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

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                                                                                                                                                                                N

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                                                                                                                                                                                2

                                                IND-HEALTH - Individual Health Care Mandate Form
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                                                                                                                                                                             July

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                                                                                                                                                                          IND-H 3

353                                                                                             354               355           356                         357                   358                                                                                      359                                                                                      360                                                                                      361                                                                                      362                                                                                      363                                                                                      364                                                                                      365                                                                                      366                                                                                      367                                                                                      368                                                                                      369                                                                                      370              371               372           373                         374                   375                                                                                      376                                                                                      377                                                                                      378                                                                                      379                                                                                      380                                                                                      381                                                                                      382                                                                                      383                                                                                      384                                                                                      385                                                                                      386                                                                                      387              388               389           390                         391                   392                                                                                      393                                                                                      394                                                                                      395                                                                                      396                                                                                      397                                                                                                                                                                              398

Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; 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","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; 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","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked Values "NC","A","B","C","D","E","F","G1","H1","H2","N","X","RI","M"; blank if not marked                                                                                                                         value = "*EOD*"

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                                                                                        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

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 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

399                                                                                      400                                                                                      401                                                                                      402                                                                                      403                                                                                      404              405               406           407                         408                   409                                                                                      410                                                                                      411                                                                                      412                                                                                      413                                                                                      414                                                                                      415                                                                                      416                                                                                      417                                                                                      418                                                                                      419                                                                                      420                                                                                      421              422               423           424                         425                   426                                                                                      427                                                                                      428                                                                                      429                                                                                      430                                                                                      431                                                                                      432                                                                                      433                                                                                      434                                                                                      435                                                                                      436                                                                                      437                                                                                      438              439                                                                  440                               441