Form Ed-03 - New Hampshire - 2015

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New Hampshire

2015

Department of

ED-03

Revenue Administration

FOR DRA USE ONLY

EDUCATION TAX CREDIT DONATION RECEIPT

PRINT OR TYPE

STEP 1

RECEIVING SCHOLARSHIP ORGANIZATION:

FEDERAL TAXPAYER IDENTIFICATION NUMBER:

STREET ADDRESS:

ADDRESS (CONTINUED):

CITY/STATE/ZIP:

STEP 2

DONATING BUSINESS ORGANIZATION/ENTERPRISE:

FEDERAL TAXPAYER IDENTIFICATION NUMBER:

STREET ADDRESS:

ADDRESS (CONTINUED):

CITY/STATE/ZIP:

STEP 3

DONATION AMOUNT: ....................................................................................................................................... $

DATE THE DONATION WAS RECEIVED: .........................................................................................................

STEP 4

I certify that the scholarship organization received the donation listed from the business organization/enterprise on the

date shown above.

AUTHORIZED SIGNATURE (IN INK)

DATE

PRINT SIGNATORY NAME & TITLE

This Donation Receipt must be filed with the Department of Revenue Administration at the address below and a copy

sent to the donor business organization/enterprise within 15 days after the receipt of the donation.

MAIL TO:

NH DRA

EDUCATION TAX CREDIT