Form Ed-02 - Education Tax Credit Application - 2015

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New Hampshire

2015

Department of

ED-02

Revenue Administration

FOR DRA USE ONLY

EDUCATION TAX CREDIT APPLICATION

PRINT OR TYPE

This application is due no earlier than January 1, 2015 and no later than June 15, 2015.

STEP 1

BUSINESS ORGANIZATION/ENTERPRISE NAME:

FEDERAL TAXPAYER IDENTIFICATION NUMBER:

STREET ADDRESS:

ADDRESS (CONTINUED):

CITY/STATE/ZIP:

TELEPHONE NUMBER:

BUSINESS ORGANIZATION/ENTERPRISE CONTACT NAME & TITLE:

EMAIL ADDRESS:

STEP 2

SCHOLARSHIP ORGANIZATION(S) TO WHICH YOU INTEND TO CONTRIBUTE AND AMOUNT OF EACH REQUESTED DONATION (IF KNOWN):

TOTAL REQUESTED ELIGIBLE DONATION AMOUNT............................................................................................. $

The maximum donation eligible for the Education Tax Credit for the 2015 Program Year is $600,000.

TAX CREDIT AMOUNT (85% of donation).................................................................................................................. $

Tax credits awarded are 85% of the donation amount on a first come, first served basis until the statutory maximum

credit limit has been reached.

STEP 3

I certify that the business organization/enterprise shall make the requested donations within 60 days of the date of

approval of this application in accordance with RSA 77-G, but no later than July 15, 2015 and I declare, under

penalties of perjury, that I have examined this document and to the best of my belief the information is true,

correct and complete.

AUTHORIZED SIGNATURE (IN INK)

DATE

PRINT SIGNATORY NAME & TITLE

MAIL TO:

NH DRA