Yes Check only one box Single 1 Federal AGI from Federal Form 1040, line 37; 1040A, line 21 or 1040EZ, line 4........................................ 2 1 Net modifications to Federal AGI from RI Schedule M, line 3. If no modifications, enter zero on this line. 3 2 Modified Federal AGI. Combine lines 1 and 2 (add net increases or subtract net decreases)................... 3 Deductions. RI Standard Deduction (left margin). If line 3 is over $192,700, see Standard Deduction Worksheet.......... 4 4 Subtract line 4 from line 3............................................................................................................................ 5 5 Exemptions. Enter federal exemptions in box, multiply by $3,850 and enter result on line 6. If line 3 is over $192,700, see Exemption Worksheet ............................. 6 6 RI TAXABLE INCOME. Subtract line 6 from line 5.................................................................................... 7 7 8 RI income tax from Rhode Island Tax Table or Tax Computation Worksheet.............................................. 9a 8 RI percentage of allowable Federal credit from page 2, RI Sch I, line 22 9b 9 RI Credit for income taxes paid to other states from page 2, RI Sch II, line 29 9c Other Rhode Island Credits from RI Schedule CR, line 7...................... 9d Total RI credits. Add lines 9a, 9b and 9c.................................................................................................... 10a Rhode Island income tax after credits. Subtract line 9d from line 8 (not less than zero)............................ 10b 10 Recapture of Prior Year Other Rhode Island Credits from RI Schedule CR, line 10................................... RI checkoff contributions from page 2, RI Checkoff Schedule, line 37....... .............. 11 11 USE/SALES tax due from page 8, RI Schedule U, line 4 or line 8, whichever applies............................... 12 12 13 TOTAL RI TAX AND CHECKOFF CONTRIBUTIONS. Add lines 10a, 10b, 11 and 12............................. 13 RI 2015 income tax withheld from RI Schedule W, line 16.... (Attach all Forms W-2 and 1099 with RI withholding, AND Sch W ) 14a 14 14b 2015 estimated tax payments and amount applied from 2014 return..... 14c Property tax relief credit from RI-1040H, line 7 or 14. Attach RI-1040H RI earned income credit from page 2, RI Schedule EIC, line 40............. 14d RI Residential Lead Paint Credit from RI-6238, line 7. Attach RI-6238. 14e 14f Other payments....................................................................................... TOTAL PAYMENTS AND CREDITS. Add lines 14a, 14b, 14c, 14d, 14e and 14f..................................... 14g AMOUNT DUE. If line 13 is LARGER than line 14g, subtract line 14g from line 13 15a 15 a b c d a b a b c d e f g a Contributions reduce your refund or increase your balance due. X $3,850 = INCOME, TAX AND CREDITS PAYMENTS AND PROPERTY TAX RELIEF CREDIT AMOUNT DUE REFUND Attach Forms W-2 and 1099 here. Rhode Island Standard Deduction Single $8,275 Married filing jointly or Qualifying widow(er) $16,550 Married filing separately $8,275 Head of household $12,400 ELECTORAL CONTRIBUTION If you want $5.00 ($10.00 if a joint return) to go to this fund, check here. (See instructions. This will not increase your tax or reduce your refund.) If you wish the 1st $2.00 ($4.00 if a joint return) to be paid to a specific party, check the box and fill in the name of the political party. Otherwise, it will be paid to a nonpartisan general account. FILING STATUS Married filing jointly Qualifying widow(er) Head of household Married filing separately 1 2 3 4 5 RETURN MUST BE SIGNED - SIGNATURE IS LOCATED ON PAGE 2 Mailing address: RI Division of Taxation, One Capitol Hill, Providence, RI 02908-5806 Your first name MI Last name Spouse’s first name MI Last name Your social security number Spouse’s social security number Daytime phone number City, town or post office State City or town of legal residence Address Deceased? ZIP code New address? Yes Yes Yes Deceased? Suffix Suffix State of Rhode Island and Providence Plantations 2015 Form RI-1040 Resident Individual Income Tax Return Check ü if RI-2210 or RI-2210A is attached and enter underestimating interest due. This amount 15b should be added to line 15a or subtracted from line 16, whichever applies. 15c TOTAL AMOUNT DUE. Add lines 15a and 15b. Complete RI-1040V and send in with your payment AMOUNT OVERPAID. If line 14g is LARGER than line 13, subtract line 13 from line 14g. If there is an amount due for underestimating interest on line 15b, subtract line 15b from line 16. 16 16 17 Amount of overpayment to be refunded...................................................................................................... 17 Amount of overpayment to be applied to 2016 estimated tax................. 18 18 b c ☺ L Check ü if extension is attached. Check ü to certify use tax amount on line 12 is accurate.

State of Rhode Island and Providence Plantations 2015 Form RI-1040 Resident Individual Income Tax Return RI SCHEDULE II - CREDIT FOR INCOME TAX PAID TO ANOTHER STATE NOTE: You must attach a signed copy of the state tax return(s) for which you are claiming credit. RI income tax from RI-1040, page 1, line 8 less allowable federal credit from RI-1040, page 2, line 22 .................... 23 23 Income derived from other state. If more than one state, see instructions................................................................. 24 24 Modified federal AGI from page 1, line 3 ..................................................................................................................... 25 25 Divide line 24 by line 25........................................................................................................................................................ 26 26 Tentative credit. Multiply line 23 by line 26........................................................................................................................... 27 27 Tax due and paid to other state (see specific instructions). Insert abbreviation for name of state paid 28 28 MAXIMUM TAX CREDIT. Line 23, 27 or 28, whichever is the SMALLEST. Enter here and on page 1, line 9b ........ 29 29 RI CHECKOFF CONTRIBUTIONS SCHEDULE Drug program account RIGL §44-30-2.4 ......................... 30 Olympic Contribution RIGL §44-30-2.1 ....... Yes $1.00 contribution ($2.00 if filing a joint return) .... 31 RI Organ Transplant Fund RIGL §44-30-2.5 ................... 30 32 RI Council on the Arts RIGL §42-75.1-1 .......................... 31 33 32 RI Nongame Wildlife Fund RIGL §44-30-2.2 ................... 33 34 Childhood Disease Victim’s Fund RIGL §44-30-2.3 ........ 34 35 RI Military Family Relief Fund RIGL §44-30-2.9 ................ 35 36 TOTAL CONTRIBUTIONS. Add lines 30, 31, 32, 33, 34, 35 and 36. Enter here and on RI-1040, page 1, line 11.......... 36 37 37 RI SCHEDULE EIC - RHODE ISLAND EARNED INCOME CREDIT Federal earned income credit from Federal Form 1040, line 66a; 1040A, line 42a, or 1040EZ, line 8a ..................... 38 Rhode Island percentage............................................................................................................................................. 39 RI EARNED INCOME CREDIT. Multiply line 38 by line 39. Enter here and on RI-1040, page 1, line 14d................. 38 40 39

40 Credit for child and dependent care expenses from Federal Form 1040, line 49 or Form 1040A, line 31............................................................................................ $1.00 $5.00 $10.00 Other RI SCHEDULE I - ALLOWABLE FEDERAL CREDIT RI income tax from page 1, line 8 ................................................................................................................................ 19 20 Tentative allowable federal credit. Multiply line 20 by 25% (0.2500).......................................................................... 21 MAXIMUM CREDIT. Line 19 or 21, whichever is SMALLER. Enter here and on page 1, line 9a ............................. 22 19 20 21 22 Name Your social security number Your signature Spouse’s signature Date Telephone number Paid preparer address City, town or post office State ZIP code PTIN Paid preparer signature Print name Date Telephone number 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. May the Division of Taxation contact your preparer? YES Revised 09/2015 10% _ . _ _ _ _ Page 2