Research & Development Tax Credit Application Form printable pdf download

Research & Development Tax Credit Application Form

FORM

DP-165

970

FOR DRA USE ONLY

NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION

RESEARCH & DEVELOPMENT TAX CREDIT APPLICATION

Taxable period end date: ____________________________ Date of Request: ________________________

month

day

year

month

day

year

Federal Employer Identification Number:

Name (Principal NH Filer if combined group):

Street Address:

5(a)

Social Security Number:

Address (continued):

5(b)

Department Identification Number:

City/State/Zip:

Contact Name & Title:

Telephone Number:

Qualified Manufacturing Research & Development expenditures (wages only) per Federal return:

Attach copy of Federal Form 6765, Credit for Increasing Research Activities

Qualified Manufacturing Research & Development expenditures (wages only) attributable to NH:

Amount of Research & Development Credit requested (Line 7 x 10%) not to exceed $50,000:

Signature (in ink)

Date

Print Name & Title

MAIL TO:

NH DRA

PO Box 488

Concord, NH 03302-0488

FOR DRA USE ONLY

R&D Tax Credit Application

DP-165

Rev. 9/07

Research & Development Tax Credit Application Form