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                           New Hampshire  
                             Department of  
                                                                DP-165                   *0DP1652311862*
                           Revenue Administration
                                                                                                                0DP1652311862

                                 RESEARCH & DEVELOPMENT TAX CREDIT APPLICATION
                                                       MMDDYYYY                                       MMDDYYYY
                                 Tax Period Begin Date                Tax Period End Date

PRINT OR TYPE
Name (Principal NH Filer if Combined Group):                                                                  Taxpayer Identification Number

Number & Street Address                                                                                             DIN FEIN                 SSN

 Address (continued)

City / Town                                            State    Zip Code + 4 (or Canadian Postal Code)
                                                        
Contact Name                                                    Contact Phone Number

EEd/dz dzW ͗         CORPORATION COMBINED GROUP                 FIDUCIARY        NON-PROFIT            PARTNERSHIP      PROPRIETORSHIP

A  Qualified Manufacturing Research & Development expenditures (wages only) per Federal Return...........  A 
      Attach copy of Federal Form 6765, Credit for Increasing Research Activities
B  Qualified Manufacturing Research & Development expenditures (wages only) attributable to NH..............B

C  Amount of Research & Development Credit requested (Line B x 10%) not to exceed $50,000......................C

                                 DO NOT SUBMIT THIS APPLICATION WITHOUT THE FEDERAL FORM 6765
Under penalties of perjury, I declare that I have examined this application and the attached returns, and to the best of my belief they are 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 application with the preparer listed below.
 TAXPAYER'S SIGNATURE & INFORMATION

 Signature (in ink)                                                                      MMDDYYYY

 Print Signatory Name & Title

 Email Address                                                                           Phone Number

PAID PREPARER'S SIGNATURE & INFORMATION
 Signature of Preparer                                                                   MMDDYYYY

 Printed Name of Preparer                                                        Preparer Identification Number     Phone Number

 Preparer's Address                                             City / Town                                   State Zip Code + 4 (or Canadian Postal Code)
                                                                                                               
      DP-165
      sĞƌƐŝŽŶ ϭ  ϴ   /202ϯ                                                                                                                   Page 1 of 2

                        New Hampshire  
                        Department of  
                                                              DP-165                          INSTRUCTIONS
                        Revenue Administration

ABOUT THE RESEARCH & DEVELOPMENT TAX CREDIT 
RSA 77-A:5, XIII allows for a Research & Development Credit for qualified manufacturing research & development ĞdžƉĞŶĚŝƚƵƌĞƐ 
incurred during the fiscal year of the company. The taxpayer shall apply for this credit using the Research and Development Tax Credit 
Application (Form DP-165) which shall be postmarked no later than June 30 following the taxable period during which research and 
development expenditure  wƐ ĞƌĞ made or incurred. For additional information, refer to the NH DRA website at www.revenue.nh.gov.   

ENTITY TYPE 
Check the entity type which corresponds to your organizational structure.  In the case of a Limited Liability Company (LLC), check the 
tax classification that corresponds to the federal return used to report the income and deductions to the IRS. 

^  d/KE  
Enter the amount of the Qualified Manufacturing Research & Development expenditures as defined in RSA 77-A:5, XIII(b), and reported 
in ƐĞĐƚŝŽŶ A or Line 24 of the Federal Form 6765 (wages only).  Attach a copy of Federal Form 6765.

^  d/KE  
Enter the amount of the Qualified Manufacturing Research & Development expenditures as defined in RSA 77-A:5, XIII(b) that are 
attributable to New Hampshire activities (wages only).

^  d/KE  
Enter the amount of Research & Development Credit requested by multiplying the New Hampshire Qualified Manufacturing Research 
& Development expenditures by 10 percent (Line B x 10%), not to exceed $50,000.

SIGNATURES and POWER OF ATTORNEY (POA)
The application must be signed and dated in ink by the taxpayer or authorized agent. Print the name and title of the officer or 
authorized agent signing the application. 

If the return was completed by a paid preparer, then the preparer must also sign and date the return in ink. The preparer must also 
enter their Federal Preparer Tax Number (PTIN) and their complete address and phone number. 

By checking the POA box, the taxpayer authorizes the Department staff to discuss this application with the paid preparer listed on this 
application.  This is a limited POA for this application only. The Department shall request a completed Form DP-2848, "Power of 
Attorney" for discussion of any other ƚĂdž ƉĞƌŝŽĚ Žƌ ŵĂƚƚĞƌ͘ 

WHERE TO FILE 
File online using Granite Tax Connect at www.revenue.nh.gov/gtc or mail to NH DRA, PO Box 457, Concord NH 03302-0457. 

                        DO NOT SUBMIT THIS APPLICATION WITHOUT THE FEDERAL FORM 6765 ͘

   DP-165
   sĞƌƐŝŽŶ ϭ  ϴ   /202ϯ                                                                                               Page 2 of 2