Rhode Island Form Tx 16 – Fill Out and Use This PDF

TX-16 (Rev 10/24/2008)

STATE OF RHODE ISLAND

DIVISION OF TAXATION - EMPLOYER TAX SECTION

1 Capitol Hill - Suite 36

Providence, Rhode Island 02908

(401) 574-8700 (Option 2) or WWW.UITAX.RI.GOV

CLAIM FOR REFUND OF TEMPORARY DISABILITY INSURANCE TAX

IMPORTANT - Please read instructions before completing

1. Enter your Name, Social Security Number, and Address.

YOUR NAME (First, Middle Initial and Last)

SOCIAL SECURITY NUMBER

NO. AND STREET

CITY

STATE

ZIP CODE

2. Enter the calendar year for which a refund is being claimed, filing date, your signature , and telephone number.

I hereby apply for a refund of taxes paid in excess during the calendar year _________ to the

R.I. Temporary Disability Insurance Fund. I certify that the facts presented including the attached W-2, are true to the best of my knowledge and belief.

Date:		Signature:					Telephone :
3. IMPORTANT - ATTACH A COPY OF FEDERAL FORM W-2 FOR EACH EMPLOYER LISTED
COMPANY TELEPHONE NUMBER:						COMPANY TELEPHONE NUMBER:
FIRM NAME OF						FIRM NAME OF
EMPLOYER						EMPLOYER
STREET & NUMBER						STREET & NUMBER
CITY STATE & ZIP			WAGE	$	-	CITY STATE & ZIP			WAGE	$	-
COMPANY TELEPHONE NUMBER:						COMPANY TELEPHONE NUMBER:
FIRM NAME OF						FIRM NAME OF
EMPLOYER						EMPLOYER
STREET & NUMBER						STREET & NUMBER
CITY STATE & ZIP			WAGE	$	-	CITY STATE & ZIP			WAGE	$	-
COMPANY TELEPHONE NUMBER:						COMPANY TELEPHONE NUMBER:
FIRM NAME OF						FIRM NAME OF
EMPLOYER						EMPLOYER
STREET & NUMBER						STREET & NUMBER
CITY STATE & ZIP			WAGE	$	-	CITY STATE & ZIP			WAGE	$	-

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TX-16(REV 10/24/2008) PAGE 2

IMPORTANT INFORMATION

1.Refunds can only be requested for the calendar years of 2007, 2008, and 2009.

2.This form should only be completed if during a prior calendar year you worked for two or more Rhode Island registered employers. The refund will be based on the amount of wages in excess of the taxable wage base to the Rhode Island Temporary Disability Insurance Fund. Those wage bases are as follows:

2007- $ 52,100.00, and 2008 - $ 54,400.00, and 2009 - $ 56,000.00

3.A separate Claim For Refund Form must be completed for each year a refund is requested.

4.Spouses cannot combine wages and must file a separate Claim For Refund Form.

5.The Rhode Island Temporary Disability Insurance Act does not allow a refund of under one dollar to be processed.

IMPORTANT INSTRUCTIONS

1.Complete all of the information in section 1 and section 2. The Claim For Refund Form cannot be processed without this information.

2.Check to make sure the calendar year and your telephone number is correct.

3.List each employer for whom you worked during the calendar year in section 3. Enter the employer name, address, employer telephone number and wages paid. List only Rhode Island registered employers from whom you received wages on which Rhode Island Temporary Disability Taxes were paid.

4.Attach a copy of Federal Form W-2 for each employer you listed. Each employer must have a different Federal Identification Number. Photocopies

of W-2 will not be accepted. W-2 Forms must be legible and will not be returned.

5.Please review your Claim For Refund Form and sign before mailing.

6.Return completed form to:

DIVISION OF TAXATION - EMPLOYER TAX SECTION

ONE CAPITOL HILL SUITE 36

PROVIDENCE, RI 02908 - 5829

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