DO NOT STAPLE
                   New Hampshire  
                       Department of                          DP-156                    *0DP1562311862*
              Revenue Administration                                                                        0DP1562311862

                                 NURSING FACILITY QUALITY ASSESSMENT RETURN
For Assessment Period: Check one and enter applicable year
January 1 - March 31   April 1 - June 30          July 1 - September 30        October 1 - December 31      Year

STEP 1 - Name, Address, & Taxpayer Identification Number
Facility Name                                                                                               Taxpayer Identification Number

Number & Street Address

Address (continued)

City / Town                                                                    State                     Zip Code + 4 (or Canadian Postal Code)
                                                                                
STEP 2 - Type of Return (check if applicable)                                                               MMDDYYYY
  Initial Return (1st filing)      Amended Return               Final Return            Last Day of Business

STEP 3 - Calculate Your Balance Due or Overpayment                             Round to the nearest whole dollar
1. Net Patient Services Revenues                                        1 

2. New Hampshire NFQA (Line 1 multiplied by 5.5% (.055))                                2 
3. Credits: 
(a) Payment made with extension                                           3(a) 
(b) Credit carried over from prior period                                 3(b) 

(c) Original Return Payment (amended returns only)                        3(c)

          Total Credits (Sum of Lines 3(a), 3(b), and 3(c))                                            3 

4. Balance of Assessment Due (Line 2 less Line 3)                                       4 
5. Additions: 
(a) Interest                                                              5(a) 
(b) Failure to Pay Penalty                                                5(b) 

(c) Failure to File Penalty                                               5(c) 

          Total Additions (Sum of Lines 5(a), 5(b), and 5(c))                                          5 

6. Balance Due (Line 4 plus Line 5). If balance due is less than zero, enter on Line 7. 6 

7. Apply overpayment amount as credit on subsequent return payment     7

DP-156  
7FSTJPO       /202               Enclose, but do not staple or tape your payment with the return                                               Page 1 of 2

                     New Hampshire  
                      Department of              DP-156       *0DP1562321862*
                Revenue Administration                        0DP1562321862

                                       NURSING FACILITY QUALITY ASSESSMENT RETURN
STEP 4 - Signatures
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 
person owning or operating the utility, this declaration is based on all information of which the preparer has knowledge.
Signature of Officer (in ink)                                 MMDDYYYY

Print Signatory Name & Title                                  Phone Number

Signature of Preparer                                         MMDDYYYY

Printed Name of Preparer                                      Preparers Tax Identification Number

Preparer's Address
                                                              Phone Number

Address (continued)

City / Town                                             State Zip Code + 4 (or Canadian Postal Code)
                                                         
MAIL TO:     NH DRA 
                            TAXPAYER SERVICES 
                            PO BOX 637 
                            CONCORD NH 03302-0637

DP-156  
7FSTJPO      1  /202                                                                                                     Page 2 of 2