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State of Rhode Island Division of Taxation
RI-1065PA
Partnership Adjustment - Federal Imputed Assessment 20113999990101
Federal employer identification number Social security number
For the taxable year from
MM/DD/YYYY through MM/DD/YYYY Address Amended
Final determination date Change Return
MM/DD/YYYY
Name
Address 1
Address 2 NAICS code
City, town or post office State ZIP code Email address
Entity Column A Column B
LLC LLP LP Partnership C Corporations Sub S Corps, Individuals,
type: LLCs, Partnerships & Trusts
1 Enter your net Rhode Island adjustments................................................................ 1a 1b
2 Enter the nonapportionable or allocable amounts included in line 1........................ 2a 2b
3 Subtract line 2 from line 1. This is the amount subject to apportionment................. 3a 3b
4 Enter the Rhode Island apportionment ratio. Carry to six (6) decimal places......... 4a 4b
_ . _ _ _ _ _ _ _ . _ _ _ _ _ _
5 Multiply the amount on line 3 by the ratio on line 4. Enter the result here............... 5a 5b
6 Enter the portion of line 2 allocated to Rhode Island............................................... 6a 6b
7 Add lines 5 and 6. Enter the total. If zero or less, enter “0”...................................... 7a 7b
8 Rhode Island tax rate............................................................................................... 8a 7.00% 8b 5.99%
9 Rhode Island Tax Due. Multiply the amount on line 7 by the applicable tax rate 9a 9b
on line 8................................................................................................................
10 Add lines 9a and 9b. This is the total tax due.............................................................................................................. 10
11 Enter the interest amount here (see instructions)........................................................................................................ 11
12 Enter the penalty amount here (see instructions)........................................................................................................ 12
13 Add lines 10, 11 and 12. This is the total amount due................................................................................................. 13
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
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