SALES & USE 
                          STATE OF RHODE ISLAND DIVISION OF TAXATION                           TAX RETURN 
                          ONE CAPITOL HILL - STE 4 - PROVIDENCE, RI 02908-5802                 QUARTERLY

NAME

ADDRESS                                                                    STQ
                                                                                               16124899990101
CITY, STATE & ZIP CODE

I HEREBY CERTIFY THAT THIS RETURN, TO THE BEST OF MY KNOWLEDGE 
AND BELIEF, IS A TRUE, CORRECT AND COMPLETE RETURN.
SIGNATURE OF OWNER, PARTNER OR AUTHORIZED AGENT

REVD FORM STQ04/2021TITLE                         DATE
                                                                           NET SALES AND USE  
                                                                           TAX DUE AND PAID   $
                    FEDERAL IDENTIFICATION NUMBER RETURN FOR QUARTER ENDING