Department of Labor and Training - EMPLOYER TAX DIVISION
                                                1511 Pontiac Avenue, Cranston, RI 02920
                                             Telephone: (401) 574-8700  | Web: https://uitax.ri.gov

               QUARTERLY TAX AND WAGE  - ADDITIONAL EMPLOYEE WAGES
Employers with 25 or more employees are required to submit wage data electronically.  The electronic filing specifications are online at:  
www.dlt.ri.gov/employers/employer-tax-unit/resources. Complete this page and attach to your TX-17 Quarter lyTax and Wage form if necessary.

Employer Name:_______________________________ Account Number: ____________________
This Report is for Year and Quarter           / 1    2        3         4                                                                   

Social Security Number      Last Name, First Initial of First Name                  Total Wages for         Number of    Hours 
                                                                                       the Quarter          Weeks Paid        Paid

                                                                                    $ 0.00
                                                                    Total Wages: ______________