Form A-105 - Disaster Relief Request
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1
2FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
A-105
DISASTER RELIEF REQUEST
STEP A
LAST NAME
FIRST NAME & INITIAL
SOCIAL SECURITY NUMBER
Print
or Type
SPOUSE/CU PARTNER’S LAST NAME
FIRST NAME & INITIAL
SOCIAL SECURITY NUMBER
NAME
ADDRESS
FEDERAL IDENTIFICATION NUMBER
BUSINESS NAME
& ID
NUMBERS
NUMBER & STREET ADDRESS
DEPARTMENT IDENTIFICATION NUMBER
ADDRESS (continued)
LICENSE NUMBER
CITY/TOWN, STATE & ZIP CODE
PHONE NUMBER
REPRESENTATIVE’S NAME
REPRESENTATIVE’S NUMBER & STREET ADDRESS
REPRESENTATIVE’S PHONE NUMBER
REPRESENTATIVE’S CITY/TOWN, STATE & ZIP CODE
STEP B
TAXABLE PERIOD BEGINNING ______________________________________ AND ENDING __________________________________________
TAX YEAR
Mo
Day
Year
Mo
Day
Year
OR TAX
TYPE
TAX TYPE (CHECK BOX OR BOXES THAT APPLY)
BUSINESS TAX (BUSINESS PROFITS TAX OR BUSINESS ENTERPRISE TAX)
MEALS & RENTALS TAX, FOR MONTH(S) ______________________
INTEREST & DIVIDENDS TAX
OTHER ______________________________________________
STEP C
REASON FOR REQUEST. SPECIFY THE CAUSE OF EVENT:
FACTS &
HOSPITALIZATION
FIRE
STORM
OTHER
ISSUES
DATE OF EVENT: ______________________________________________ CITY/TOWN OF EVENT LOCATION: _________________________________________________
STEP D
BANK NAME
BANK PHONE NUMBER
BANK
BANK ADDRESS
STEP E
RECALCULATE A TAX ASSESSMENT/BILL
REINSTATE DENIED MEALS & RENTALS COMMISSION
ACTION
REQUESTED
ABATE PENALTIES
APPROVE RETURN EXTENSION WITHOUT PENALTY
RECONSIDERATION OF REFUND REQUEST
APPROVE PAYMENT EXTENSION WITHOUT PENALTY
OTHER _________________________________________________________________________________________________________________________
STEP F
Enclose a copy of the Notice of Assessment or Letter of Denial, if applicable. If a representative is being used, a Power of Attorney
REQUIRED
(POA), Form DP-2848 must be fi led with the Department of Revenue Administration. Attach a copy of documents used to verify
DOCU-
disaster.
MENTS
Check this box if you have fi led a Power of Attorney (POA), Form DP-2848 with the Department of Revenue Administration for
the above referenced tax period.
x
SIGNATURE OF TAXPAYER (IN INK)
DATE
SPOUSE/CU PARTNER’s SIGNATURE (IN INK)
DATE
SIGNATURE OF REPRESENTATIVE (IN INK)
DATE
NH DRA
MAIL
109 PLEASANT STREET
PO BOX 454
TO:
A-105
CONCORD, NH 03302-0454
Rev. 09/2011
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