Form Dp-175 - Registration For Electronic Funds Transfer Of Business Tax Payment

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NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
FORM
REGISTRATION FOR ELECTRONIC FUNDS TRANSFER
DP-175
OF BUSINESS TAX PAYMENT
NEW HAMPSHIRE’S BANK ACCOUNT INFORMATION WILL BE PROVIDED TO YOU ALONG WITH YOUR APPROVAL
IMPORTANT
FOR THE NEW HAMPSHIRE EFT PROGRAM.
New Hampshire requires all taxpayers having a total liability for Business Profits Tax, RSA 77-A, and/or a Business
Enterprise Tax, RSA 77-E, of $100,000 or greater for the most recently filed tax year to submit tax payments by
electronic funds transfer (EFT). Taxpayers with tax liabilities under the mandatory threshold of $100,000 may also
participate in New Hampshire’s EFT program.
If you meet the mandatory threshold to make your tax payments via EFT, you must submit this form to register as an
WHEN TO USE
EFT taxpayer with the New Hampshire Department of Revenue. If you are below the mandatory threshold, but wish to
voluntarily participate in the EFT program, you must submit this form to register with the Department. The information
provided on this form should include the name, address and telephone number of the contact person(s) for EFT
purposes. In addition, this form should be used to report any changes in your registration information (i.e., a change
in taxpayer contact, telephone number, etc). This form is available in the EFT Program Information Guide and in the
New Hampshire Package X. The Package X form does not include the instructions or record formats required to
make your payments via EFT. If you use the Package X form, please contact DRA’s Document Processing Division at
(603) 271-2186 for the complete EFT Program Information Guide.
This form must be filed at least 30 days prior to the due date of your first EFT payment. Any changes in the registration
WHEN TO FILE
information must be provided to the Department at least 30 days prior to the change.
PRENOTE TEST
All taxpayers participating in New Hampshire’s EFT program are required to complete a successful Prenote Test at
least 10 calendar days prior to the due date of their first EFT payment.
WHERE TO FILE
Mail To: NH Dept Revenue Administration, Document Processing Division, PO Box 1004, Concord, NH 03302-1004.
Call the NH Department of Revenue Administration, Document Processing Division at (603) 271-2186. Hearing or
NEED HELP
speech impaired individuals may call TDD Access: Relay NH 1-800-735-2964.
Registration for Electronic Funds Transfer Payment
Please Print or Type
Taxpayer Name
Proprietor's Social Security Number
Check one of the following:
ENTITY TYPE:
FEIN
Corporation
1
Proprietorship
3
Partnership
4 Fiduciary
2
Combined Group
5
Non-Profit Organization
6
Primary Contact Person
Telephone
Fax Number
(
)
(
)
Secondary Contact Person
Fax Number
Telephone
(
)
(
)
Number and Street Address
City or Town, State & Zip Code
New Registration
Change Document
Please check one of the following:
FOR DRA USE ONLY
NH DEPT OF REVENUE ADMINISTRATION
Approved by
DOCUMENT PROCESSING DIVISION
Mail
Date
PO BOX 1004
To:
CONCORD NH 03302-1004
(603)271-2186
DP-175
Rev. 12/99

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