Print Form                   Reset Form

                                New Hampshire                       202  
                                Department of                                     3         *0DP59A2311862*
                              Revenue Administration                DP-59-A                                    0DP59A2311862

                                          PAYMENT FORM AND APPLICATION FOR 7-MONTH  
                                EXTENSION OF TIME TO FILE INTEREST AND DIVIDENDS TAX RETURN
DO NOT FILE THIS FORM IF LINE 3 IS NEGATIVE OR ZERO                                             MAKE YOUR PAYMENTS ONLINE AT 
            THIS IS NOT AN EXTENSION OF TIME TO PAY                                                     GRANITE TAX CONNECT 
                                                                                                        www.revenue.nh.gov/gtc

For the CALENDAR year 202  3 or other taxable period beginning:                         ENTITY TYPE - Check One
MMDDYYYY                                       MMDDYYYY
                                   and ending:                                            1 - Individual/Joint     3 - Partnership/LLC   4 - Estate
0 1 0             1 2 0 2 3                    1 2 3   1 2 0 2 3

Last Name
CHAMBERS 
First Name                                           MI              Social Security Number                         Taxpayer Identification Number
CHRIS                                                L                     8    9 7 4   5 6 1 2 3

Spouse's Last Name                                                                                                             If issued a DIN, use DIN in the 
                                                                                                                               appropriate taxpayer 
CHAMBERS                                                                                                                       identification  box.  
First Name                                           MI              Social Security Number                                    DO NOT enter SSN or FEIN

BETTY                                                A                     4    5 6 1 2   3 7 8 9

Name of Partnership, Estate, or LLC

Number & Street Address
28 OLD GRAND RD 
Address (continued)

City / Town                                                                         State     Zip Code + 4 (or Canadian Postal Code)
SUNAPEE                                                                             NH        0 3     7 8      2

100% PAYMENT IS DUE ON OR BEFORE THE DUE DATE OF THE TAX                                                                       Round to the nearest whole dollar
File online at Granite Tax Connect        1        Enter 100% of the Interest and Dividends Tax determined to be due (net of   
  www.revenue.nh.gov/gtc                       RSA 77-G Education Tax Credit)                                                            5  6        8         5
                                          2(a)   Enter credit carried over from prior   
Make check payable to:                         year and total estimated tax payments                           7 5 0
         State of New Hampshire     
Mail to: NH DRA                           2(b)   Enter payment previously made,  
  PO BOX 1265                                         if applicable                                            4 0 0
  CONCORD NH 03302-1265 
                                          2        Total advance payments and credits 
  Enclose, but do not staple or tape your            (Line 2(a) plus Line 2(b))                                                          1  1 5                0
      payment to this extension.          3        NET BALANCE DUE:  
  If negative or zero DO NOT file this               (Line 1 minus Line 2)                  Pay This Amount                              4  5        3         5
                  application.

  VersionDP-59-A 1202 07/2023 3                                                                                                        Page 1 of 2

                                   New Hampshire             202  
                                   Department of                       3
                                   Revenue Administration   DP-59-A

                                     PAYMENT FORM AND APPLICATION FOR 7-MONTH  
                                   EXTENSION OF TIME TO FILE INTEREST AND DIVIDENDS TAX RETURN

DO NOT FILE THIS FORM IF LINE 3 IS NEGATIVE OR ZERO                                   MAKE YOUR PAYMENTS ONLINE AT 
                                                                                      GRANITE TAX CONNECT 
                      THIS IS NOT AN EXTENSION OF TIME TO PAY
                                                                                      www.revenue.nh.gov/gtc

WHO MUST FILE 
Taxpayers who have not paid 100% of the Interest and Dividends Tax determined to be due by the due date of the tax and are requesting a 7-month 
extension to file their Interest and Dividends Tax return. To make an additional payment in order to have paid 100% of the tax determined to be due, 
you may submit this form with payment or make your payment electronically by accessing Granite Tax Connect at www.revenue.nh.gov/gtc by the 
original due date of the tax.  An extension will not be granted if 100% of the tax determined to be due is not paid timely.   

Do not file this form if Net Balance Due (Line 3) is zero .

Enter the beginning and ending dates of the taxable period. 

TAXPAYER IDENTIFICATION  
The Commissioner of the Department of Revenue is authorized pursuant to RSA 21-J:27-a to require submission of an SSN, FEIN, or any other 
identifying number used in filing or preparing federal tax documents.  If you do not have any such identifying number, or share one with another 
taxpayer, then, under N.H. Code of Admin. Rules, Rev 2903.01, you must obtain a Department Identification Number (DIN).  If you have a DIN, use it 
on all New Hampshire filings.  To ensure that your filings and payments are applied to the correct account, the sequence of names and taxpayer ID 
numbers on all filings must be consistent. The failure to provide a taxpayer identification number may result in the rejection of filed documents.  
Failure to timely file documents complete with a consistent taxpayer identification number may result in the imposition of penalties and interest, the 
disallowance of claimed exemptions, exclusions, credits, deductions, or an adjustment that may result in increased tax liability.  

Enter the taxpayer's name and taxpayer identification number in the spaces provided.  

AUTOMATIC EXTENSION 
If you have paid 100% of your Interest & Dividends Tax determined to be due by the due date of the tax, you will be granted an automatic 7-month 
extension to file your New Hampshire Interest and Dividends Tax return WITHOUT filing this form. If you meet this requirement, you may file your 
New Hampshire Interest and Dividends Tax return up to 7 months beyond the original due date of the return and you will not be subject to the late 
filing penalty. Note that an extension of time to file your return is not an extension of time to pay the tax.  

WHEN TO FILE 
This form must be postmarked on or before the original due date of the return. Electronic payments must be received before midnight on the due 
date of the tax. 

WHERE TO FILE 
File online at Granite Tax Connect www.revenue.nh.gov/gtc or mail to NH DRA, PO Box 1265, Concord, NH 03302-1265. 

E-FILE 
If you pay online, you do not need to file this form.  Electronic payments must be received before midnight on the due date of the tax. 

REASONS FOR DENIAL 
Applications for extensions will be denied for reasons such as, but not limited to, the application was postmarked after the due date for filing the 
return, or the payment of the balance due shown on Line 3 did not accompany the application or was not received electronically before midnight on 
the due date of the tax. 

NEED HELP? 
Questions not covered here may be answered in our “Frequently Asked Questions” available on our website at: www.revenue.nh.gov or call Taxpayer 
Services at (603) 230-5920, Monday through Friday, 8:00 am to 4:30 pm. All written correspondence to the Department should include the taxpayer 
name, taxpayer identification number, the name of a contact person and a daytime telephone number. Individuals who need auxiliary aids for 
effective communications in programs and services of the New Hampshire Department of Revenue Administration are invited to make their needs 
and preferences known. Individuals with hearing or speech impairments may call TDD Access: Relay NH 1-800-735-2964.

                                                                                                                                   Page 2 of 2
      VersionDP-59-A 1202 07/2023 3