Edit and Instructions                        value =T1               assigned by NACTP incremented if items included in barcode are changed, default ="0001"                        2024     RI1040N                                                                             #########                                                              #########  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

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         YES

                                                                                                                                                                                                                                                                                                                                                                                      HEADER SECTION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 YES
                                                                                                                                                                                                                                                                             Tax Year 2024  Rhode Island Form RI-1040NR  2D Barcode Layout                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      RI-1040NR INFORMATION
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     DEMOGRAPHIC INFORMATION

                                                                                                                                                                                                                                                                                                                                                   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                               RI Standard Deduction                           Modified Federal AGI                                                                           Exemption amount

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     1                                               2                                               4                                               3                                                                                              6
                                                                                                                                                                                                                                                                                                                                           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 "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 "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 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

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                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                               N                                                                                              N

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

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            RI Schedule I                                                 NULL FOR NR NULL FOR NR NULL FOR NR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             NULL FOR NR

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              RI-1040H Property Tax Relief
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              RI Checkoff Contributions Schedule

Number of exemptions                            Allowable Federal Credit                        All income from RI            Non-Resident with income outside RI Part Year Resident with income from outside RI Credits                                      Recapture of RI Credits                         Checkoff Contributions                          RI Sales & Use Tax                              Use tax amount is accurate    Full-year HC Coverage Checkbox Individual Mandate Penalty                      Schedule W                                      Estimates                                       Nonresident Withholdings                        RI EIC                                          Other Payments                                  Total Payments                                  Previously issued Overpayments                  2210 amount                                     Balance Due                                     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                                                                                         Drug Program account                            Olympic                                         Organ Transplant                                Council on the Arts                             Non-Game wildlife                               Childhood Disease Victims Fund                  Military Family Relief Fund                     Behavioral Health                               Total Contributions                                                                            Federal EIC

6                                               9                                               11                            11                                  11                                          12                                              13b                                             14                                              15a                                                                                                          15b                                             17a                                             17b                                             17c                                             17d                                             17e                                             17f                                             17g                                             18b                                             18c                                             20                                              21                                                                                                                                                                                                                                             23                                                                                                                    26                                              27                                              28                                              29                                              30                                              31                                              32                                              33                                              34                                                                                             35
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           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

                                                                                                                                                                                                                    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                             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

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

                                                                                                                                                                                                                    12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              6                     12                                              12                                                                          8                  8                12                                              12                                              12                                              12                                              12                                              12                                                                                             12

                                                                                                                                                                                                                                                                    09/30/2024

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                                                                                                                                                            RI-6238 
NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR            NULL FOR NR

                                                                                                                                                                                     Sch II - Full Year Nonresident                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Sch III - Part Year Resident

                                                                                                                                                                                                                    Wages, salaries and tips - RI                   Wages, salaries and tips - Fed                  Interest Dividends - RI                         Interest Dividends - Fed                        Business Income - RI                            Business Income - Fed                           Sale or exchange of Property - RI               Sale or exchange of Property - Fed              Pension - RI                                    Pension - Fed                                   Farm Income - RI                                Farm Income - Fed                               Miscellaneous Income - RI                       Miscellaneous Income - Fed                      Adjustments to AGI - RI                         Adjustments to AGI - Fed                        Net Modifications- RI                           Net Modifications - Fed                         Allocation Percentage RI Tax After Federal Credits                    Allocated RI Tax                                                            Resident Date from Resident Date to Wages, salaries and tips - Fed                  Wages, salaries and tips - RI                   Wages, salaries and tips - NonRes RI            Interest Dividends - Fed                        Interest Dividends - RI                         Interest Dividends - Fed                                                                       Business Income - Fed

                                                                                                                                                                                                                    SchII-1a                                        SchII-1b                                        SchII-2a                                        SchII-2b                                        SchII-3a                                        SchII-3b                                        SchII-4a                                        SchII-4b                                        SchII-5a                                        SchII-5b                                        SchII-6a                                        SchII-6b                                        SchII-7a                                        SchII-7b                                        SchII-9a                                        SchII-9b                                        SchII-11a                                       SchII-11b                                       SchII-13              SchII-14                                        SchII-15                                                                    SchIII             SchIII
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          SchIII-1a                                       SchIII-1b                                       SchIII-1d                                       SchIII-2a                                       SchIII-2b                                       SchIII-2d                                                                                      SchIII-3a

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 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                 mmddyyyy

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

12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              6                     12                                              12                                              12                                              2                        12                                              12                                                                        12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                              12                                                       12                                              12                                                      12                                              12                                              12                                                      12                                                              8

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                09/30/2024

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Schedule M - Modifications

Business Income - RI                            Business Income - Fed                           Sale or exchange of Property - Fed              Sale or exchange of Property - RI               Sale or exchange of Property - Fed              Pension - Fed                                   Pension - RI                                    Pension - Fed                                   Farm Income - Fed                               Farm Income - RI                                Farm Income - Fed                               Miscellaneous Income - Fed                      Miscellaneous Income - RI                       Miscellaneous Income - Fed                      Adjustments to AGI - Fed                        Adjustments to AGI - RI                         Adjustments to AGI - Fed                        Net Modifications - Fed                         Net Modifications- RI                           Net Modifications - Fed                         Allocation Percentage RI Tax After Federal Credits                    Allocated RI Tax                                Income Taxed other state                        Tax Due other state name Tax Due other state paid                        Total AGI other state                                                     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

SchIII-3b                                       SchIII-3d                                       SchIII-4a                                       SchIII-4b                                       SchIII-4d                                       SchIII-5a                                       SchIII-5b                                       SchIII-5d                                       SchIII-6a                                       SchIII-6b                                       SchIII-6d                                       SchIII-7a                                       SchIII-7b                                       SchIII-7d                                       SchIII-9a                                       SchIII-9b                                       SchIII-9d                                       SchIII-11a                                      SchIII-11b                                      SchIII-11d                                      SchIII-14             SchII-15                                        SchIII-16                                       SchIII-18                                       SchIII-22                SchIII-22                                       SchIII-24                                                                 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

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

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

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

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

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                NULL FOR NR NULL FOR NR NULL FOR NR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     NULL FOR NR NULL FOR NR                                       NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR            NULL FOR NR

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Schedule CR - RI Credits

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Schedule MU - Tax Paid to Other States

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

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

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

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

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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                09/30/2024

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    RI -2210
NULL FOR NR NULL FOR NR NULL FOR NR NULL FOR NR            NULL FOR NR
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Schedule U - Use Tax
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Schedule W - Withholding

                                                                          Schedule NR-MU - Taxes Paid to Other States

                                                                                                                     Income Taxed other state                        Tax Due other state name Tax Due other state paid                        Total AGI other state                           Income Taxed other state                        Tax Due other state name Tax Due other state paid                        Total AGI other state                           Income Taxed other state                        Tax Due other state name Tax Due other state paid                        Total AGI other state                           RI Income Tax                                                       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

                                                                                                                     NR-MU 3                                         NR-MU 7                  NR-MU 7                                         NR-MU 9                                         NR-MU 14                                        NR-MU 18                 NR-MU 18                                        NR-MU 20                                        NR-MU 25                                        NR-MU 29                 NR-MU 29                                        NR-MU 31                                        NR-MU 35                                                            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

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

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

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

1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               1                             1                                                                                  9               9                                               5                                                            1                           1                           40                9                     8

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    DRAFT 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Schedule E - Exemption Schedule

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

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

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)

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

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

                                                                                                                                                                                                                                                         09/30/2024

                                                                                                                                                                                                                DRAFT 

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

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

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

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

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

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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     DRAFT 

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

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

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

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

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

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               09/30/2024

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                DRAFT 

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

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

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                               442