DO NOT STAPLE

                           New Hampshire                      202  
                           Department of                                             *00DP102311862*
                                                              DP-10
                          Revenue Administration                                                              00DP102311862

                                                 INTEREST AND DIVIDENDS TAX RETURN

                                                              MMDDYYYY                          MMDDYYYY
For the CALENDAR year 202  or other taxable period beginning:                        and ending:

STEP 1  -  PRINT OR TYPE                         Check box if there has been a name change since last filing.              Due Date for CALENDAR 
Last Name                                                                                                                  year filers is on or before  
                                                                                                                           April 15, 202  
                                                                                                                           Due Date for FISCAL year 
First Name                                           MI       Social Security Number                             filers is the 15th day of the 
                                                                                                                           4th month after  
                                                                                                                           the close of the  
                                                                                                                           taxable period.
Spouse's Last Name
                                                                                                                 If you have a DIN, use the DIN 
                                                                                                                           in the taxpayer ID box. 
                                                                                                                           DO NOT use FEIN or SSN
First Name                                           MI       Social Security Number                            Taxpayer Identification Number

Name of Partnership, Estate, or LLC

Number & Street Address

Address (continued)                                                                                             Unit Type                                  Unit #
                                                                                                                  
City / Town                                                             State        Zip Code + 4 (or Canadian Postal Code)
                                                                         
STEP 2  -  Return Type and Alternate Address
                                                                                         % of NEW HAMPSHIRE Ownership 
ENTITY TYPE - Check One                                                                  Interest in Entity Type
        1 - INDIVIDUAL               - JOINT        3 - PARTNERSHIP/LLC 4 - ESTATE

                           MMDDYYYY                                                                           Date of Death
        INITIAL RETURN                                  Established NH Residency  FINAL DECEASED

                           MMDDYYYY                                                                           Social Security Number 
        FINAL RETURN                                    Abandoned NH Residency

        AMENDED RETURN              IRS ADJUSTMENT: A complete federal Revenue Agent Report (RAR) with all applicable Schedules must be included with a complete amended NH 
                                    tax return.  Do not use this form to report  IRS adjustments for taxable periods ending on or before December 31, 2020.

        DP-10 202                                                                                                                    Page 1 of 5
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                             New Hampshire                               202  
                              Department of                                                           *00DP102321862*
                                                                         DP-10
                        Revenue Administration                                                                               00DP102321862

                                             INTEREST AND DIVIDENDS TAX RETURN - continued

STEP 3  -  Read instructions before you begin

                                                        INTEREST & DIVIDENDS FROM ALL SOURCES                                          Round to the nearest whole dollar
1      From Your Federal Income Tax Return: (See Instructions) 
       (a) Interest Income. Enter the amount from Line 2(b) of your federal return                                       1(a)
       (b) Dividend Income. Enter the amount from Line 3(b) of your federal return                                       1(b)

       (c) Federal Tax-Exempt Interest Income. Enter the amount from Line 2(a) of your federal return                    1(c)

       (d) Subtotal Interest and Dividends Income. (Sum of Lines 1(a), 1(b) and 1(c))                             Subtotal    1(d)

2      List Taxable Annuities or Actual Cash & Property Distributions From S-Corporations, Trusts/Estates, Partnerships, and LLCs: 
       Entity Codes:      = S-CORPORATIONS;      = PARTNERSHIPS;       = TRUSTS OR ESTATES;       = LLC;       = FOUNDATIONS;       = OTHER 
       I                                                II                                                        III                       IV 
Entity Code                                        Name of Payor                                               Payor's ID Number            Distribution Amount

                                                                                      Total from supplemental schedule attached

2      Total Distributions (Sum of Column IV above)                        2

3      Subtotal Gross Interest and Dividends Income and Distributions (Line 1(d) plus Line 2)                         Subtotal    3

4      List payors and amounts of interest and/or dividends NOT TAXABLE to New Hampshire included on Lines 1(a), 1(b), 1(c) and/or 2:  
       I                                                II                                                        III                       IV 
Reason Code                                          Name of Payor                                             Payor's ID Number            Non-Taxable Amount

       (a) Subtotal of non-taxable income above (Sum of Column IV)         4(a)

       (b) Total non-taxable income from supplemental schedule (Attached)   4(b)

       (c) Non-taxable income (Subtotal of Lines 4(a) plus 4(b))           4(c)

       (d) Part-year resident non-taxable income pro rata share            4(d)

            DP-10 202                                                                                                                       Page 2 of 5
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                        New Hampshire                              202  
                          Department of                                                             *00DP102331862*
                                                                   DP-10
                   Revenue Administration                                                                       00DP102331862

                                     INTEREST AND DIVIDENDS TAX RETURN - continued
STEP 3  -  (continued)  Read instructions before you begin

                                                   INTEREST & DIVIDENDS FROM ALL SOURCES                        Round to the nearest whole dollar
4      Total Non-Taxable Income (Sum of Line 4(c) plus Line 4(d))                                              4

5      Gross Taxable Income (Line 3 minus Line 4)                                                         5

6      Less: $2,400 for Individual, Partnership and Estate; $4,800 for Joint filers                                                 6            2400

7     Adjusted Taxable Income (Line 5 minus Line 6) If less than zero, use minus sign.                     7                          -2400

                                                                                      Year of Birth                                 Year of Birth
       Blind            Spouse Blind               65 (or over) or disabled                         Spouse 65 (or over) or disabled 

8       Check the exemptions that apply.    Total number of boxes checked             x $1200 =               8

9      Net Taxable Income (Line 7 minus Line 8). If less than zero, use minus sign.                        9                          -2400

       DP-10 202                                                                                                                      Page 3 of 5
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                            New Hampshire                                202  
                                  Department of                                                      *00DP102341862*
                                                                         DP-10
                        Revenue Administration                                                             00DP102341862

                                                  INTEREST AND DIVIDENDS TAX RETURN - continued

STEP 4  -  Calculate Your Tax, Credits, Interest and Penalties                                                               Round to the nearest whole dollar

10     New Hampshire Interest and Dividends Tax                                                                       10
           (Line 9 multiplied by  %) 

11      RSA 77-G Education Tax Credit                                           11

12    New Hampshire Interest and Dividends Tax Net of Education Tax                                                   12
     Credit (Line 10 minus Line 11.  If negative enter zero) 

13     Payments:  
           (a) Tax paid with application for extension                          13(a)

           (b) Current year estimated tax payments                              13(b)

           (c) Credit carryover from prior tax period                           13(c)
                                                                                                           13   Subtotal of Lines 13(a) through 13(d)
           (d) Paid with original return (Amended returns only)                 13(d)

14     Subtotal Due (Line 12 minus Line 13 Subtotal)                                                                  14

15    Additions to Tax: 
           (a) Interest                                                        15(a)

           (b) Failure to Pay                                                  15(b)

           (c) Failure to File                                                 15(c)
                                                                                                           15   Subtotal of Lines 15(a) through 15(d)
           (d) Underpayment of Estimated Tax                                   15(d)

STEP 5  -  Calculate Your Net Balance Due or Overpayment
16        (a) Subtotal Due (Line 14 plus Line 15 Subtotal)                      16(a)

           (b) Return Payment Made Electronically                                                          16(b)

17    Net Balance Due (Line 16(a) minus Line 16(b))  
            (Make Check Payable to State of New Hampshire)                                           17    PAY THIS AMOUNT   

18    OVERPAYMENT  
            (If balance due is less than zero, enter on Line 18)       18
19    Amount of Line 18 to be applied to: 
           (a) Credit - Next Year's Tax Liability (Not available for Federal RAR)    19(a)   DO NOT PAY

           (b) Refund (Only option available for Federal RAR)                           19(b)   DO NOT PAY 

           DP-10 202                                                                                                         Page 4 of 5
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                      New Hampshire                                  202  
                        Department of                                                *00DP102351862*
                                                                     DP-10
                   Revenue Administration                                                              00DP102351862

                          INTEREST AND DIVIDENDS TAX RETURN - continued
Under penalties of perjury, I declare that I have examined this return and to the best of my belief it is true, correct and complete. If 
prepared by a person other than the taxpayer, this declaration is based on all information of which the preparer has knowledge.

     POA:  By checking this box and signing below, you authorize us to discuss this return with the preparer listed below.

TAXPAYER'S SIGNATURE & INFORMATION
Signature (in ink)                                                                   MMDDYYYY

If joint return, BOTH parties must sign, even if only one had income                 MMDDYYYY

Print Signatory Name(s) (and Title if applicable)

Taxpayer's Phone Number
                                                 Filing as surviving spouse          Form 1310 attached

PAID PREPARER'S SIGNATURE & INFORMATION
Signature of Preparer                                                                MMDDYYYY

Printed Name of Preparer

Preparer's Phone Number                          Preparer Identification Number

Preparer's Address

City / Town                                                                    State Zip Code + 4 (or Canadian Postal Code)
                                                                                
Mail to:                  Make Check Payable to:   
                                                                                     FILE ONLINE AT GRANITE TAX CONNECT 
NH DRA                    STATE OF NEW HAMPSHIRE 
                                                                                     www.revenue.nh.gov/gtc
PO Box 637                Enclose but DO NOT staple or tape your 
Concord NH 03302-0637                            attachments

     DP-10 202                                                                                                             Page 5 of 5
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