Form Ed-05 - Scholarship Organization Report - 2015 Page 4
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4New Hampshire
2015
Department of
ED-05
Revenue Administration
SCHOLARSHIP ORGANIZATION REPORT (continued)
The number of participating students who graduated from high school in the previous year and the number that
11.
dropped out of school.
(a) Number
graduated ........................................................
(b) Number
dropped out
.....................................................
12. Provide an explanation of information omitted from the report because it would reveal private data about an
individual student.
13(a) Provide the name of any other scholarship organizations who have agreed to combine their data with your
scholarship organization data for the purposes set forth in RSA 77-G:2, II. The agreement shall only be
considered valid if each scholarship organization lists the other scholarship organizations in the agreement.
13(b) If you have an agreement to combine data with another scholarship organization, does this report reflect the
combined data or just the data for the scholarship organization that prepared this report?
Under penalties of perjury, I declare that I have examined this document and to the best of my belief the
information herein is true, correct and complete. I do hereby attest that the scholarship organization is in full
compliance with the provisions of RSA 77-G, the Education Tax Credit statute.
AUTHORIZED SIGNATURE (IN INK)
DATE
PRINT SIGNATORY NAME & TITLE
MAIL TO:
NH DRA
EDUCATION TAX CREDIT
PO BOX 488
CONCORD NH 03302-0488
ED-05
Rev 1 10/2014
Page 4 of 4
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