Form A-105 - Disaster Relief Request (Page 2 of 2) in pdf

Form A-105 - Disaster Relief Request Page 2

FORM

NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION

A-105

DISASTER RELIEF REQUEST

INSTRUCTIONS

Complete your request by typing or legibly printing in the spaces provided.

File Form A-105, Disaster Relief Request, with the NH Department of Revenue Administration to request relief as a result of

the 2011 Tropical Storm Irene.

Step A: Unless otherwise informed in writing by the requesting party, all orders, notices and communications shall be

made to:

a) the party’s listed address and phone number; or

b) the representative’s address and phone number (see Step F).

Step B: Enter the tax period(s) that is the subject of your request. Check the appropriate box(es) to indicate what tax(es)

you were unable to timely pay and/or fi le due to the disaster.

Step C: The taxpayer has the burden to document the disaster that hinders their ability to meet their filing requirements or

payment requirements to the Department of Revenue Administration. State with specificity all of the reasons for your

request. Attach additional sheets if necessary, such as copies of hospital bills, insurance claims or newspaper articles

that confirms your disaster event.

Step D: If the reason you were unable to make a timely payment is due to a disaster affecting your bank, enter the name

of your bank, branch address where your account is located, and the telephone number of the bank.

Step E: Describe the action(s) that you are requesting of the Department.

Step F: Enclose a copy of the Notice of Assessment (Tax Bill) or Letter denying your request, if applicable. Form

DP-2848, Power of Attorney (POA) must be fi led with the Department if a representative is being assigned.

Keep a copy of this document for your fi le.

FILING INSTRUCTIONS

File your request with:

New Hampshire Department of Revenue Administration

Disaster Relief Request

109 Pleasant Street

PO Box 454

Concord, NH 03302-0454

A-105

Instructions

Rev. 09/2011

Form A-105 - Disaster Relief Request Page 2