New Hampshire                                     Print Form          Reset Form
                                                        Payment 
                            Department of  
                                                        Voucher          *0NHPYT2311862*
                    Revenue Administration
                                                                                            0NHPYT2311862
                                                        INSTRUCTIONS 

1  Select the tax type for which the payment applies. 
2  For a Business Tax or Interest and Dividend Tax payment, select the appropriate entity type.  For Meals and Rentals (M&R) Tax, 
select All Entity Types. 
3  Enter the beginning and ending date of the taxable period for which the payment applies. 
4  Select the Taxpayer Identification Number type (Social Security Number (SSN), Federal Employer Identification Number (FEIN), 
Department Identification Number (DIN), or M&R License Number) and enter number.  For a Joint entity type, please enter 
Identification Number of the primary filer. 
5  Enter the amount paid. 
6  Enter the taxpayer's name and address.  For a joint entity type, please enter the information for the primary filer. 

Make your check payable to: STATE OF NEW HAMPSHIRE 
Do not staple or tape the voucher and check together. 

If you are making payments for multiple tax periods or multiple tax types, please provide a voucher for each tax period and each tax 
type and indicate the amount you wish to be applied to each tax period and each tax type. 

Mail this voucher with your payment to: 
NH DRA                                                          Pay online at Granite Tax Connect 
PO BOX 1265 
CONCORD, NH 03302-1265                                                www.revenue.nh.gov/gtc

Need Help?  Call the Department at (603) 230-5920, Monday through Friday, 8:00am - 4:30pm
                                                           DO NOT CUT
1 Tax Type                   2 Entity Type
    Business                   Corporation        Combined      Partnership  Proprietorship      Fiduciary              Non-Profit
  Interest & Dividends         Individual/Joint   Partnership   Estate
  Meals & Rentals              All Entity Types
                               MMDDYYYY                              MMDDYYYY
3 Taxable period beginning:    0   1 0    1 2   0 2   3 and ending:  1 2 3   1 2 0          2 3
4  Taxpayer Identification #
                                                                                                 5 Amount Paid
    FEIN                DIN    SSN        M&R License Number

  4 8  4        8        9 6 4 5   4                                                                                    5 0 0
6  Taxpayer Name
 Last Name                                                      First Name                                                        MI
 PATCHES                                                        BRUCE                                                             M
 Business Name

 Number & Street Address
 12 OAK LANE 
 Address (continued)

 City / Town                                                    State        Zip Code + 4 (or Canadian Postal Code)
 CONCORD                                                        NH           0 3          3   0 1

    NH-PYT 
    Version 1.  1 10/2023