State of Rhode Island, Department of Labor and Training, Workers Com pensation Unit P.O. Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8006 Web: www.dlt.state.ri.us NOTICE OF WITHDRAWAL OF DESIGNATION AS INDEPENDENT CONTRACTOR PURSUANT TO R.I.G.L. 28 -29 -17.1 * I, (Name) _______________________________ Soc. Sec. No. ______________________ * Business Name __________________________ FEIN # ___________________________ * Address ________________________________ Business License #__________________ ________________________________________ Date of Birth _______________________ * hereby withdraw my Designation as Independent Contractor for: * Hiring Entity Name: __________________________________________ * Address: _______ ___________________________________ __________________________________________ __________________________________________________________________ Signature * Date * This information is available to the public. Information on this form may be shared within the Department of Labor and Training, the Rhode Island Division of Taxation and the Internal Revenue Service. Form is not valid until received and date stamped by this Department. For a dated receipt copy, include a copy with the original sent to the Department of Labor and Training with a SELF -ADDRESSED, STAMPED ENVELOPE. The original and copy will be date stamped . The original will be retained for our files. The stamped copy will be returned in the envelo pe provided. DWC-11-ICR (1/01)