1. Refunds can only be requested for the last three calendar years.

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 for that year. Please see the application instructions.

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