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