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4 State of Rhode Island Division of Taxation 4
5 Form RI-941 5
6 Employer’s Quarterly Tax Return and Reconciliation 19106099990101 6
7 7
8 8
9 Name Federal employer identification number 9
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99-9999999 10
11 Address For the quarter ending: 11
12 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MMDDYYYY 12
13 Address 2 E-mail address 13
14 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 14
15 City, town or post office State ZIP code 15
16 XXXXXXXXXXXXXXXXXXXXXXXX XX 99999 Amended Return 16
17 17
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.
18 Weekly payers: Enter the RI state income tax withheld during for each week in the appropriate column and row. 18
19 Monthly payers: Enter the RI state income tax withheld during each month of the quarter using the “Total” row ONLY (see boxes below). 19
20 Quarterly payers: Enter the RI state income tax withheld during the quarter in the “3rd MONTH” column, “Total” row ONLY (see box below). 20
See instructions for more detail.
21 21
22 MONTH 1st MONTH OF QUARTER 2nd MONTH OF QUARTER 3rd MONTH OF QUARTER 22
23 23
24 Week 1 999999999999999 99 999999999999999 99 999999999999999 99 24
25 25
26 Week 2 999999999999999 99 999999999999999 99 999999999999999 99 26
27 27
28 Week 3 999999999999999 99 999999999999999 99 999999999999999 99 28
29 29
30 Week 4 999999999999999 99 999999999999999 99 999999999999999 99 30
31 31
32 Week 5 999999999999999 99 999999999999999 99 999999999999999 99 32
33 33
Monthly
34 payers use 34
35 Total 999999999999999 99 999999999999999 99 999999999999999 99 these 3 35
36 boxes 36
37 Quarterly payers enter your amount here 37
38 38
39 39
40 1 State income tax withheld from wages, tips, and other compensation for this quarter................................ 1 999999999999 99 40
41 41
42 2 State income tax withholding payments made to the RI Division of Taxation to date for this quarter.......... 2 999999999999 99 42
43 43
44 3 State income tax withholding amount due and paid with this return. Subtract line 2 from line 1................ 3 999999999999 99 44
45 45
46 46
47 47
48 4 Number of employees who received wages, tips, and other compensation for this quarter.............................. 4 999999999999999 48
49 49
50 5 Total amount of wages, tips, and other compensation for this quarter ........................................................ 5 999999999999 99 50
51 51
52 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 52
53 belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. 53
54 Authorized officer signature Print name Date Telephone number 54
55 XXXXXXXXXXXXXXXXXXXXX 04/30/2022 (401) 999-9999 55
56 Paid preparer signature Print name Date Telephone number 56
57 57
58 XXXXXXXXXXXXXXXXXXXXX 04/30/2022 (401) 999-9999 58
Paid preparer address City, town or post office State ZIP Code PTIN
59 59
60 XXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XX 99999 P99999999 60
61 61
62 May the Division of Taxation contact your preparer? YES 62
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34567890123456789012345678901234567890123456789012345678901234567890123456789012Mail to RI Division of Taxation - One Capitol Hill - Providence, RI 02908 Revised
10/2020