Form Au-22 - Certification Request Form - Department Of Revenue Administration
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1NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
FORM
AU-22
FOR DRA USE ONLY
CERTIFICATION REQUEST FORM
Steps 1 through 5 must be completed. If not, your request shall be considered incomplete and rejected.
Fee Paid? Yes
No
BUSINESS NAME
TAXPAYER IDENTIFICATION NUMBER
STEP 1
PRINT OR
NUMBER & STREET ADDRESS
DEPARTMENT IDENTIFICATION NUMBER
TYPE
ADDRESS (CONTINUED)
NH SECRETARY OF STATE IDENTIFICATION NUMBER
CITY/TOWN, STATE, ZIP CODE
MEALS & RENTALS TAX LICENSE NUMBER
COMPANY CONTACT NAME & TELEPHONE NUMBER
COMMUNICATIONS SERVICE TAX REGISTRATION NUMBER
IS CERTIFICATION LETTER TO BE SENT TO NAME & ADDRESS ABOVE?
ENTITY TYPE
LLC FILING AS:
Yes
No
CORPORATION
PROPRIETOR
PARTNERSHIP
IF NO, ATTACH A POWER OF ATTORNEY (FORM DP-2848) AUTHORIZING US TO
SEND TO ADDRESS OTHER THAN BUSINESS ADDRESS ABOVE.
STATEMENT OF
CERTIFICATE OF
STATEMENT FOR
STEP 2
GOOD STANDING
DISSOLUTION
WITHDRAWAL
REQUEST
TYPE
STEP 3
LINE 1
Date registered with Secretary of State's offi ce to conduct business in New Hampshire:
INFORMATION
LINE 2(a) Date of last business activity in New Hampshire
(b) If this is a request for a Withdrawal or Dissolution, has a fi nal return encompassing the last day of business been fi led?
Yes
No
If no, attach fi nal return to request, or indicate date fi nal return will be fi led: ___________________
LINE 3
Reason for request:
LINE 4 Which taxes have you fi led with NH in the past? (Check all that apply and enter 4-digit year)
Interest and Dividends Tax ________
Real Estate Transfer Tax ________
Communications Services Tax________
Y Y Y Y
Y Y Y Y
Y Y Y Y
Business Taxes ________
Meals and Rentals Tax ________
Other ______________________________
Y Y Y Y
Y Y Y Y
Y Y Y Y
LINE 5 If fi ling as part of Combined Group indicate Name and Taxpayer Identifi cation Number (TIN) of Company under which this
entity fi les its NH returns:
LINE 6 If requesting taxpayer is considered a disregarded entity for federal purposes (SMLLC), indicate Name and TIN of
Company under which this entity reports its business activity federally:
STEP 4
(a) Have you included a non-refundable fee of $30.00 made payable to the State of New Hampshire?
Yes
No
ATTACHMENTS
Yes
No
(b) Is the requesting company dissolving or liquidating?
If yes, see instructions for this line.
(c)
For Good Standing requests, see Instructions for this line.
STEP 5
SIGNATURE
AND TITLE
SIGNATURE (IN INK) OF CORPORATE OFFICER/PARTNER/MEMBER/PROPRIETOR
DATE
PRINT SIGNATORY NAME
TITLE
Please note that the NH Department of Revenue Administration has approximately 60 days in which to respond for a Dissolution or
Withdrawal and approximately 30 days for a Good Standing.
FORM
CERTIFICATION REQUEST
AU-22
PAYMENT FORM
FOR DRA USE ONLY
FOR DRA USE ONLY
BUSINESS NAME
Good Standing
Dissolution
Withdrawal
TAXPAYER IDENTIFICATION NUMBER
009
006
006
30.00
NH DRA
Statement request Fee
$
AUDIT DIVISION
Make check payable to:
MAIL
PO BOX 457
State of New Hampshire
TO:
CONCORD NH 03302-0457
AU-22
Rev 04/2011
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