New Hampshire  
                        Department of                               DP-175           *0DP1752311862*
             Revenue Administration
                                                                                                         0DP1752311862

          ELECTRONIC  FUNDS TRANSFER ACH CREDIT REGISTRATION FOR BUSINESS TAX PAYMENTS

                                                          GENERAL INSTRUCTIONS
 PRENOTE TEST                                                                    WHAT TO FILE
 All taxpayers participating in New Hampshire's ACH CREDIT program are           Any business taxpayer interested in making tax payments via ACH 
 required to complete a successful Prenote Test at least 10 calendar days        CREDIT, must submit this form to register as an ACH CREDIT taxpayer 
 prior to the due date of their first ACH CREDIT payment. Do not send            with the New Hampshire Department of Revenue Administration. The 
 payment via ACH CREDIT until you have received confirmation of a                information provided on this form should include the name, address and 
 successful prenote.                                                             telephone number of the primary and secondary contact person(s) for ACH 
 New Hampshire Department of Revenue Administration's Bank Account               CREDIT purposes. In addition, this form should be used to report any 
 information will be provided to you along with the Department's approval for    changes in your registration information (i.e., a change in taxpayer contact, 
 the New Hampshire EFT ACH CREDIT program.                                       telephone number, etc.).
 WHEN TO FILE                                                                    WHERE TO FILE
 This form must be filed at least 30 days prior to the due date of your first    New Hampshire Department of Revenue Administration, Taxpayer 
 ACH CREDIT payment. Any changes in the registration information must be         Services Division, PO Box 637, Concord, NH 03302-0637.
 provided to the Department at least 30 days prior to the change. Any 
 changes of financial institution and contacts require additional prenote tests. NEED HELP?
                                                                                 Call Taxpayer Services at (603) 230-5920, Monday through Friday, 
 WHO CAN FILE                                                                    8:00am-4:30pm. Hearing or speech impaired individuals may 
 The New Hampshire ACH CREDIT program is limited to filers making                call TDD Access: Relay NH at 1-800-735-2964. .
 payments for Business Enterprise Tax and Business Profits Tax liabilities. 

PRINT OR TYPE
Taxpayer First Name                                  Taxpayer Last Name                                  Taxpayer Identification Number
EMANUAL                                              ROBINS                                              4      4     4       4 4     4    4   4        4
Business Name
                                                                                                                DIN            FEIN     SSN

Number and Street Address
7654 ANCHOR RD 
Address Continued
UNIT 5
City/Town                               State        Zip/Postal Code
CONCORD                                 NH           0 3 3 0 2
Primary Contact First Name    Primary Contact Last Name     Primary Contact Email             Primary Contact Phone Number     Primary Contact Fax Number

Secondary Contact First Name  Secondary Contact Last Name   Secondary Contact Email           Secondary Contact Phone NumberSecondary Contact Fax Number

Please check one of the following:      New Registration            Change Request
ENTITY TYPE (Check one of the following):               NOTE:  If you are filing as a Combined group, you must check Combined Group. 
  Corporation-2               Combined Group-6            Fiduciary-4            Non-Profit-5 Partnership-3                 Proprietorship-1

 MAIL
 TO:      NH DRA, TAXPAYER SERVICES, PO BOX 637, CONCORD NH 03302-0637

          THIS REGISTRATION IS FOR THE ACH CREDIT PROGRAM ONLY. 
          YOU DO NOT HAVE TO REGISTER TO FILE ACH DEBIT. 

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                                                                                                                                        DP-175
                                                                                                                                      Rev: 1.  0 04/2023