New Hampshire
                                                                     202  
                            Department of                                                     *BETEXT2411862*
                           Revenue Administration                    BT-EXT                                          BETEXT2411862

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

PRINT OR TYPE                                 100% OF TAX PAYMENT IS DUE ON OR BEFORE THE ORIGINAL DUE DATE OF THE TAX

For the CALENDAR year 202         or other taxable period beginning:                  ENTITY TYPE   Check one of the following 
MMDDYYYY                                      MMDDYYYY                                   Proprietorship       Corporation                 Partnership
                                  and ending
                                                                                         Fiduciary            Non-Profit Organization     Combined Group
Proprietor's Last Name
                                                                                                                               If issued a DIN, 
                                                                                                                                use DIN in appropriate 
                                                                                                                          taxpayer identification box.
First Name                                                   MI                Social Security Number
                                                                                                                               DO NOT enter SSN or FEIN 
                                                                                                                               if you have a DIN.

Corporate, Partnership, Estate, Trust, Non-Profit or LLC Name

Taxpayer Identification Number                      Principal Business Activity Code (Federal)

Number & Street Address

Address (continued)

City / Town                                                                           State         Zip Code + 4 (or Canadian Postal Code)
                                                                                       
                                                                                                                               306/% 50 5)& /&"3&45 8)0-& %0--"3
1   Enter 100% of the Business Enterprise Tax  #&5  determined to be due (net of credit)                               1

2   Enter 100% of the Business Profits Tax  #15  determined to be due (net of credit)                                  2

3   Subtotal (Line 1 plus Line 2)                                                                                      3

4   LESS: Credit carried over from prior year and total estimated tax payments                                         4

5   BALANCE DUE: 
(If negative or zero, %0 /05 '*-& this GPSN  "T MPOH BT      PG UIF #&5 BOE #15 UBY EVF IBT CFFO                      5
QBJE CZ UIF EVF EBUF  BO BVUPNBUJD   NPOUI FYUFOTJPO UP GJMF XJMM CF HSBOUFE )

Mail to:                                        Make Check Payable to:   
                                                                                              FILE ONLINE AT GRANITE TAX CONNECT 
NH DRA                                     STATE OF NEW HAMPSHIRE 
PO Box 1265                          Enclose but DO NOT staple or tape your                               HUD SFWFOVF OI HPW 5"1 @ 
Concord NH 03302-1265                         payment to this extension

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