INCOME, TAX AND CREDITS

Using a paper clip, please attach Forms W-2 and 1099 here. Rhode Island Standard Deduction Single $9,050

Married filing jointly or Qualifying widow(er) $18,100

Married filing separately $9,050

Head of household $13,550 RETURN MUST BE SIGNED - SIGNATURE IS LOCATED ON PAGE 2 Mailing address: RI Division of Taxation, One Capitol Hill, Providence, RI 02908-5806 4 1 Federal AGI from Federal Form 1040 or 1040-SR, line 11 ........................................................... 2 1 Net modifications to Federal AGI from RI Sch M, line 3. If no modifications, enter 0 on this line. 3 2 Modified Federal AGI. Combine lines 1 and 2 (add net increases or subtract net decreases)..... 3 RI Standard Deduction from left. If line 3 is over $ 210,750 see Standard Deduction Worksheet ........... 4 Subtract line 4 from line 3. If zero or less, enter 0........................................................................ Enter # of exemptions from RI Sch E, line 5 in box, multiply by $4,250 and enter result on line 6. If line 3 is over $210,750, see Exemption Worksheet RI TAXABLE INCOME. Subtract line 6 from line 5. If zero or less, enter 0................................... 5 6 7 9d RI income tax from Rhode Island Tax Table or Tax Computation Worksheet............................... 9a 8 RI percentage of allowable Federal credit from page 3, RI Sch I, line 22...................................................................... 9b 9 RI Credit for income taxes paid to other states from page 3, RI Sch II, line 29..................................................................... 9c Other Rhode Island Credits from RI Schedule CR, line 8...... Total RI credits. Add lines 9a, 9b and 9c................................................................................. ............. a b c Recapture of Prior Year Other Rhode Island Credits from RI Schedule CR, line 11.................... d a b 10a 10b 5 6 7 8 10 RI checkoff contributions from page 3, RI Checkoff Schedule, line 37. 11 11 USE/SALES tax due from RI Schedule U, line 4 or line 8, whichever applies.............................. 12a 12 Individual Mandate Penalty (see instructions). Check ü to certify full year coverage. 12b Rhode Island income tax after credits. Subtract line 9d from line 8 (not less than zero) ............. Contributions reduce your refund or increase your balance due X $4,250 = * * If filing an amended return, attach the Explanation of Changes supplemental page TOTAL RI TAX AND CHECKOFF CONTRIBUTIONS. Add lines 10a, 10b, 11, 12a and 12b....... 13 a 13a a b Yes 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) be paid to a specific party, check the box and fill in the name of the political party. Other- wise, it will be paid to a nonpartisan general account. Check one Single FILING STATUS Married filing jointly Qualifying widow(er) Head of household Married filing separately Your first name

MI Last name Suffix Spouse’s name

MI Last name Suffix Address Your social security number Spouse’s social security number City, town or post office State ZIP code Check each box that applies. Other- wise, leave blank. Primary deceased? New address? Spouse deceased? Amended Return? City or town of legal residence ð ð ð ð ð State of Rhode Island Division of Taxation 2021 Form RI-1040 Resident Individual Income Tax Return Check ü to certify use tax amount on line 12a is accurate. 21100199990101

State of Rhode Island Division of Taxation 2021 Form RI-1040 Resident Individual Income Tax Return - page 2 2021 estimated tax payments and amount applied from 2020 return.... 14c Property tax relief credit from RI-1040H, line 13. Attach RI-1040H........ 14d RI earned income credit from page 3, RI Schedule EIC, line 40............ 14e RI Residential Lead Paint Credit from RI-6238, line 7. Attach RI-6238.. 14f Other payments...................................................................................... TOTAL PAYMENTS AND CREDITS. Add lines 14a, 14b, 14c, 14d, 14e and 14f......................................... AMOUNT DUE. If line 13b is LARGER than line 14i, subtract line 14i from line 13b.................................... b c d e f g a 14b 14g 14h 15 Enter the amount of underestimating interest due from Form RI-2210 or RI-2210A. (attach form) This amount should be added to line 15a or subtracted from line 16, whichever applies............................. TOTAL AMOUNT DUE. Add lines 15a and 15b. Complete RI-1040V and send in with your payment b c 15b 15c AMOUNT OVERPAID. If line 14i is LARGER than line 13b, subtract line 13b from line 14i. If there is an amount due for underestimating interest on line 15b, subtract line 15b from line 16.................. Amount of overpayment to be refunded........................................................................................................ Amount of overpayment to be applied to 2022 estimated tax................ 18 16 17 16 17 18 14 14a a RI 2021 income tax withheld from RI Schedule W, line 16. You must attach Sch W AND all W-2 and 1099 forms with RI withholding. ........... 13 b TOTAL RI TAX AND CHECKOFF CONTRIBUTIONS from line 13a............................................................... 13b Previously issued overpayments (if filing an amended return)..................................................................... h NET PAYMENTS. Subtract line 14h from line 14g........................................................................................ i 14i Spouse’s signature

Spouse’s driver’s license number and state 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 12/2021 15a PAYMENTS AND PROPERTY TAX RELIEF CREDIT Your social security number Name(s) shown on Form RI-1040 or RI-1040NR Your signature Your driver’s license number and state Date Telephone number J L 21100199990102

RI income tax from page 1, line 8 ................................................................................................................... 19 19 Credit for child and dependent care expenses from Federal Form 1040 or 1040-SR, Schedule 3, line 2 or 13g 20 20 Tentative allowable federal credit. Multiply line 20 by 25% (0.2500).............................................................. 21 21 MAXIMUM CREDIT. Line 19 or 21, whichever is SMALLER. Enter here and on page 1, line 9a................. 22 22 RI income tax from RI-1040, page 1, line 8 less allowable federal credit from RI-1040, page 3, line 22 ....... 23 23 24 Income derived from other state. If more than one state, see instructions.................................................... 25 24 Modified federal AGI from page 1, line 3......................................................................................................... 26 25 Divide line 24 by line 25 ........................................................................................................................................ 27 26 Tentative credit. Multiply line 23 by line 26............................................................................................................. 28 27 Tax due and paid to other state (see specific instructions). Insert abbreviation for state paid 29 28 MAXIMUM TAX CREDIT. Line 23, 27 or 28, whichever is the SMALLEST. Enter here and on pg 1, line 9b 29 Drug program account RIGL §44-30-2.4 ............ 30 30 Olympic Contribution RIGL §44-30-2.1 ....... Yes $1.00 contribution ($2.00 if a joint return) 31 31 RI Organ Transplant Fund RIGL §44-30-2.5 ...... 32 32 33 RI Council on the Arts RIGL §42-75.1-1 ............. 34 33 RI Nongame Wildlife Fund RIGL §44-30-2.2 ..... 35 34 Childhood Disease Victim’s Fund RIGL §44-30-2.3 and Substance Use and Mental Health Leadership Council of RI RIGL §44-30-2.11 ............................... 36 35 RI Military Family Relief Fund RIGL §44-30-2.9 .... 36 TOTAL CONTRIBUTIONS. Add lines 30 through 36. Enter here and on RI-1040, page 1, line 11 .................... 37 37 Federal earned income credit from Federal Form 1040 or 1040-SR, line 27a................................................ 38 38 State of Rhode Island Division of Taxation 2021 Form RI-1040 Resident Individual Income Tax Return - page 3 Your social security number RI SCHEDULE II - CREDIT FOR INCOME TAX PAID TO ANOTHER STATE RI CHECKOFF CONTRIBUTIONS SCHEDULE RI SCHEDULE EIC - RHODE ISLAND EARNED INCOME CREDIT RI SCHEDULE I - ALLOWABLE FEDERAL CREDIT $1.00 $5.00 $10.00 Other Rhode Island percentage................................................................................................................................ 39 39 RI EARNED INCOME CREDIT. Multiply line 38 by line 39. Enter here and on RI-1040, page 2, line 14d ............................................................ 40 40 15% Name(s) shown on Form RI-1040 or RI-1040NR (ATTACH COPY OF OTHER STATE(S) RETURN) _ . _ _ _ _ 21100199990103

State of Rhode Island Division of Taxation 2021 RI Schedule W Rhode Island W-2 and 1099 Information - Page 4 1 2 3 4 5 6 7 16 Total RI Income Tax Withheld. Add lines 1 through 15, Col. E. Enter total here and on RI-1040, line 14a or RI-1040NR, line 17a................................................................................................................................................. Total number of W-2s and 1099s showing Rhode Island Income Tax Withheld ...................................................... 17 Column A Enter “S” if Spouse’s W-2 or 1099 Name(s) shown on Form RI-1040 or RI-1040NR Complete this Schedule listing all of your and, if applicable, your spouse’s W-2s and 1099s showing Rhode Island Income Tax withheld. W-2s or 1099s showing Rhode Island Income Tax withheld must still be attached to the front of your return. Failure to do so may delay the processing of your return. ATTACH THIS SCHEDULE W TO YOUR RETURN Column B Enter 1099 letter code from chart Column C Employer’s Name from Box C of your W- 2 or Payer’s Name from your Form 1099 Column D Employer’s state ID # from box 15 of your W-2 or Payer’s Federal ID # from Form 1099 Column E Rhode Island Income Tax Withheld (SEE BELOW FOR BOX REFERENCES) 8 9 10 11 12 13 14 15 Your social security number Schedule W Reference Chart Form Type Letter Code for Column B Withholding Box Form Type Letter Code for Column B Withholding Box Form Type Letter Code for Column B Withholding Box W-2 17 1099-G G 11 1099-OID O 14 W-2G W 15 1099-INT I 17 1099-R R 14 1042-S S 17a 1099-K K 8 RI-1099E E 11 1099-B B 16 1099-MISC M 15 RI-1099PT P 9 1099-DIV D 15 1099-NEC N 5 21101099990101

(A) Name of Dependent State of Rhode Island Division of Taxation 2021 RI Schedule E Exemption Schedule for RI-1040 and RI-1040NR b 2 b c d e Enter the number of boxes checked on lines 1a and 1b ........................................................ 3 Yourself 1a Name(s) shown on Form RI-1040 or RI-1040NR Your social security number EXEMPTIONS f g h i j k l m 4 b c 5 Enter the number of children from lines 2a through 2m who lived with you ........................... Enter the number of children from lines 2a through 2m who did not live with you due to divorce or separation ................................... .......................................................................... Enter the number of other dependents from lines 2a through 2m not included on lines 4a or 4b. Add the numbers from lines 3 through 4c. Enter here and in the box on RI-1040/NR, pg 1, line 6 . Spouse (B) Social Security Number (C) Date of Birth (D) Relationship Complete this Schedule listing all individuals you can claim as a dependent. ATTACH THIS EXEMPTION SCHEDULE TO YOUR RETURN Failure to do so may delay the processing of your return. 3 4a 4b 4c 5 a a Exemption Number Summary Page 5 21105999990101