State of Rhode Island Division of Taxation 
     Form RI-941 
     Employer’s Quarterly Tax Return and Reconciliation               19106099990101

Name                                                                  Federal employer identification number

Address                                                               For the quarter ending:
                                                                                                                                MMDDYYYY
Address 2                                                             E-mail address

City, town or post office             State ZIP code
                                                                                               Amended Return

Enter the RI state income tax withheld during this quarter and due to the RI Division of Taxation based on the payment frequency required by law. 
     Weekly payers: Enter the RI state income tax withheld during for each week in the appropriate column and row. 
     Monthly payers:  Enter the RI state income tax withheld during each month of the quarter using the “Total” row ONLY (see boxes below). 
     Quarterly payers:  Enter the RI state income tax withheld during the quarter in the “3rd MONTH” column, “Total” row ONLY (see box below). 
     See instructions for more detail.
MONTH     1st MONTH OF QUARTER              2nd MONTH OF QUARTER                    3rd MONTH OF QUARTER

Week 1

Week 2

Week 3

Week 4

Week 5

                                                                                                                                                 Monthly  
                                                                                                                                                 payers use 
  Total                                                                                                                                          these 3 
                                                                                                                                                 boxes
                                                                      Quarterly payers enter your amount here

1 State income tax withheld from wages, tips, and other compensation for this quarter................................           1

2 State income tax withholding payments made to the RI Division of Taxation to date for this quarter..........                  2

3 State income tax withholding amount due and paid with this return.  Subtract line 2 from line 1................               3

4 Number of employees who received wages, tips, and other compensation for this quarter..............................           4

5 Total amount of wages, tips, and other compensation for this quarter ........................................................ 5

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and 
belief, it is true, accurate and complete.  Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
 Authorized officer signature         Print name                                   Date                                          Telephone number

 Paid preparer signature              Print name                                   Date                                          Telephone number

 Paid preparer address                City, town or post office State           ZIP Code                                                     PTIN

                                      May the Division of Taxation contact your preparer?   YES

                              Mail to RI Division of Taxation - One Capitol Hill - Providence, RI 02908                                           Revised 
                                                                                                                                                 10/2020

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