Form Dp-59-A - Payment Voucher And Extension Application For Interest And Dividends Tax Return

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FORM

NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION

DP-59-A

PAYMENT VOUCHER AND EXTENSION APPLICATION

043

FOR INTEREST AND DIVIDENDS TAX RETURN

IMPORTANT:

If you have paid 100% of the tax determined to be due by the original due date of the return you will be granted an

automatic 7-month extension to file your New Hampshire Interest and Dividends Tax return WITHOUT filing this

form or a copy of your Federal Extension.

If you meet this requirement, you may file your New Hampshire Interest & Dividends Tax return up to 7 months beyond the original

due date and you will not be subject to the late filing penalty. Please note that an extension of time to file your return is not an

extension of time to pay the tax.

WHEN TO USE THIS FORM:

If you need to make an additional payment in order to have paid 100% of the tax determined to be due by the original due date, then

you must complete this form and submit with payment to be granted an extension of time to file your New Hampshire Interest and

Dividends Tax return.

WHEN TO FILE: This form must be postmarked on or before the original due date of the return.

REASONS FOR DENIAL: Applications for extensions will be rejected for reasons such as, but not limited to, failure to

complete the tax payment schedule, absence of the taxpayer’s or authorized agent’s signature, the application was postmarked

after the due date for filing the return, or if the payment for the balance due shown on line 3 below did not accompany this

application.

WHERE TO FILE: NH DEPT REVENUE ADMINISTRATION, Document Processing, PO Box 2072, Concord, NH 03302-2072.

NEED HELP: Call the Taxpayer Assistance Office, at (603) 271-2186. Hearing or speech impaired individuals may call TDD

Access: Relay NH 1-800-735-2964.

Application for 7-Month Extension of Time to File

PLEASE

LAST NAME

FIRST NAME & INITIAL

SOCIAL SECURITY NUMBER

SPOUSE’S LAST NAME

FIRST NAME & INITIAL

TYPE

SPOUSE’S SOCIAL SECURITY NUMBER

NAME OF PARTNERSHIP OR FIDUCIARY

NUMBER AND STREET

FEDERAL EMPLOYER IDENTIFICATION NUMBER

(PARTNERSHIP OR FIDUCIARY)

CITY OR TOWN, STATE, AND ZIP CODE

1998

For CALENDAR year

or other tax year beginning

ending

Day

Year

Day

Year

ENTITY TYPE — Check one:

Individual/Joint

Partnership

Fiduciary

TAX PAYMENT SCHEDULE

1 Enter 100% of the tax determined to be due................................................................................................1

2 LESS: Credits and payments of estimated tax............................................................................................2

3 BALANCE DUE: Make check payable to: State of New Hampshire........................................................3

Enclose, but do not staple or tape, your payment to this extension. (If negative or zero you are not

required to file this extension application.)

Under the penalties of perjury, I declare that I have examined this application, and to the best of my belief it is true, correct, and complete. If prepared

by a person other than the taxpayer, this declaration is based on all information of which the preparer has knowledge.

Signature

Date

NH DEPT REVENUE ADMINISTRATION

MAIL

DOCUMENT PROCESSING DIVISION

TO:

PO BOX 2072

CONCORD, NH 03302-2072

D P - 5 9 - A