DO NOT ATTACH TO RETURN

                            New Hampshire  
                             Department of                            DP-9           *000DP92311862*
                     Revenue Administration                                                                                                     000DP92311862

                             SMALL BUSINESS CORPORATION ("S" CORP) INFORMATION REPORT

Name of "S" Corporation                                                                                                                   Federal Employer ID Number  Calendar Year

Number & Street Address                                                                                                                   City / Town

Address (continued)                                                                                                                       State      Zip Code + 4 (or Canadian Postal Code)
                                                                                                                                           
Total of all actual distributions made to New Hampshire residents for the period end ...............................................     $

Shareholder Name and Address (New Hampshire Residents ONLY)

Last Name                                               First Name                   MI                                                         Social Security Number

Number & Street Address
                                                                                                                                                Amount of Distribution

City / Town                                             State         Zip Code + 4 (or Canadian Postal Code)
                                                         
Last Name                                               First Name                   MI                                                         Social Security Number

Number & Street Address
                                                                                                                                                Amount of Distribution

City / Town                                             State         Zip Code + 4 (or Canadian Postal Code)
                                                         
Last Name                                                First Name                  MI                                                         Social Security Number

Number & Street Address
                                                                                                                                                Amount of Distribution

City / Town                                             State         Zip Code + 4 (or Canadian Postal Code)
                                                         
Last Name                                               First Name                   MI                                                         Social Security Number

Number & Street Address
                                                                                                                                                Amount of Distribution

City / Town                                             State         Zip Code + 4 (or Canadian Postal Code)
                                                         
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                  New Hampshire  
                       Department of                               DP-9    *000DP92311862*
              Revenue Administration                                                                     000DP92321862

Last Name                                               First Name                              MI       Social Security Number

Number & Street Address
                                                                                                         Amount of Distribution

City / Town                                             State      Zip Code + 4 (or Canadian Postal Code)
                                                         
Last Name                                               First Name                              MI       Social Security Number

Number & Street Address
                                                                                                         Amount of Distribution
City / Town                                             State Zip Code + 4 (or Canadian Postal Code)
                                                         
Last Name                                               First Name                              MI       Social Security Number

Number & Street Address
                                                                                                         Amount of Distribution
City / Town                                             State      Zip Code + 4 (or Canadian Postal Code)
                                                         
Last Name                                               First Name                              MI       Social Security Number

Number & Street Address
                                                                                                         Amount of Distribution

City / Town                                             State      Zip Code + 4 (or Canadian Postal Code)
                                                                                                         If additional space is required, 
                                                                                                         attach another sheet.

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.)
Signature (in ink) of Officer                                      Print Signatory Name & Title             MMDDYYYY

Signature (in ink) of Paid Preparer Other Than Taxpayer            MMDDYYYY
                                                                                                         DO NOT FILE WITH BUSINESS 
Print Preparer's Name                                              Preparer's Tax ID Number              RETURN. MAIL UNDER SEPARATE 
                                                                                                         COVER TO ADDRESS BELOW.
Number & Street Address
                                                                                                         FILE ONLINE AT GRANITE TAX CONNECT 
Address (continued)                                                                                      WWW.REVENUE.NH.GOV/GTC
                                                                                                         Or Mail To:  NH DRA 
                                                                                                                  PO BOX 637 
City / Town                                             State Zip Code + 4 (or Canadian Postal Code)              CONCORD NH 03302-0637   
                                                         
DP 9   202                                                                                                                     Page 2 of 3
7FSTJPO     0 /202 

                   New Hampshire                                             SMALL BUSINESS 
                    Department of       DP-9                                 CORPORATION ("S" CORP) 
              Revenue Administration                                         INFORMATION REPORT

                                        INSTRUCTIONS

W)0 .645 '*-&
The report must be completed by every subchapter "S" corporation which has made actual or constructive distributions to its New 
Hampshire shareholders during the year, per RSA 77:17-a. 

W)"5 50 '*-&
Actual distributions from "S" corporations made to New Hampshire residents are taxable to the individual recipient under New 
Hampshire Interest & Dividends Tax law.  "S" corporations are required to use this form to report such distributions.  Report any 
actual distributions from current year or prior year accumulated profits (as defined in RSA 77 and Rev 901).  Do not report the 
shareholders' proportionate share of the "S" corporation's income (loss) as shown on the individual or shareholders' Federal 
Schedule K-1. 

NOTE:   If more than 8 shareholders received actual distributions from the "S" corporation during the period, attach an additional 
     sheet listing the required information for each additional shareholder. 

W)&/ 50 '*-&
This report is due annually on or before May 1st, after the end of the year.  Pursuant to RSA 77:17-a, a list of New Hampshire 
shareholders during the preceding year together with the amount of dividends paid to each must be reported on this form. 

W)&3& 50 '*-&
File online using Granite Tax Connect at www.revenue.nh.gov/gtc or mail to NH DRA, PO Box 637, Concord, NH 03302-0637. 

FORMS SHALL NOT BE FILED BY FAX OR EMAIL

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