State of Rhode Island 
                                    DEPARTMENT OF BUSINESS REGULATION 
                                                 Securities Division  
                                                 1511 Pontiac Avenue, Bldg. 69-2 
                                                 Cranston, Rhode Island  02920 

          MANDATORY ADDENDUM TO LICENSE APPLICATION 
                     Tax Payer Status Affidavit / Identity Verification 

All  persons applying or renewing  any license, registration,  permit or other authority (herein 
after called “licensee”) to conduct a business or occupation in the State of Rhode Island are 
required to file  all applicable tax returns and pay all taxed owed to the state prior to receiving  a 
          license as mandated by State law (RIGL                   § 5-76-2) except as noted below. 
          In order to verify that the State is not owed taxes, licensees are required to provide  their 
          Social Security Number or Federal Tax Identification  Number (for businesses) as appropriate. 
          These numbers  will be transmitted  to the Division of Taxation to verify tax status prior to the 
                                                 issuance of a license. 

PLEASE CHECK ONE BOX ONLY, EVEN IF YOU HAVE NEVER BEEN EMPLOYED IN RHODE                            ISLAND. 

                                                 Licensee Declaration 
I hereby declare, under penalty of perjury, that:
     I do not have a tax liability in Rhode Island at this time.
     I have filed all required state tax returns and have paid all taxes owed.
     I have entered a written installment agreement to pay delinquent taxes that is satisfactory to the Tax Administrator.
     I am currently pursuing administrative review of taxes owed to the state.

     I am in federal bankruptcy. (Case #_________________________ )

     I am in state receivership. (Case #__________________________ )

     I have been discharged from Bankruptcy. (Case #_________________________ )

_____________________________________________________________________________________ 
Type of Professional/  Business License for which you are applying 

__________________________________                                    _____________________________________ 
Full Name (Please Print or Type)                                      Social Security Number  (or FEIN for Business) 

__________________________________                                    _____________________________________ 
Signature                                                             Phone Number  (including  area  code if not 401) 

__________________________________                                    ______________________________________ 
Date                                                                  Name of Business 

NOTE: This form must be completed, signed and attached  electronically  to your application in order for us to 
begin processing.  Please  call the Department  with any questions.