Form Ed-06 - Complaint Form - 2015
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1
2New Hampshire
2015
Department of
ED-06
Revenue Administration
FOR DRA USE ONLY
COMPLAINT FORM
PRINT OR TYPE
STEP 1
COMPLAINANT INFORMATION
4.
HOME PHONE NUMBER:
NAME:
1.
5.
WORK PHONE NUMBER:
ADDRESS:
2.
6.
EMAIL ADDRESS:
ADDRESS (CONTINUED):
3.
CITY/STATE/ZIP:
STEP 2
10.
PARTY AGAINST WHOM COMPLAINT IS ALLEGED
TELEPHONE NUMBER:
7.
NAME:
8.
ADDRESS:
ADDRESS (CONTINUED):
9.
CITY/STATE/ZIP:
STEP 3
CONCISE STATEMENT CONCERNING THE ALLEGED VIOLATION INCLUDING CITATION OF APPLICABLE SECTION OF RSA 77-G AND/OR
11.
REV 3200:
12.
STATEMENT OF FACTS: Please explain the basis for your complaint. (Use additional sheets if necessary) Attach any and all documentation to
support the complaint.
13.
NAMES AND PHONE NUMBERS OF WITNESSES:
STEP 4
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.
COMPLAINANT'S SIGNATURE (IN INK)
DATE
PRINT SIGNATORY NAME & TITLE
MAIL TO:
NH DRA
EDUCATION TAX CREDIT
PO BOX 488
CONCORD NH 03302-0488
ED-06
Rev 1 10/2014
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