DO NOT STAPLE
                   New Hampshire  
                        Department of                          DP-153                  *0DP1532411862*
                 Revenue Administration                                                                    0DP1532411862

                                                 M&%*$"*% &/)"/$&.&/5 5"9 3&563/
                                                 MMDDYYYY                                          MMDDYYYY
                           Tax Period Begin Date                     Tax Period End Date

STEP 1 - PRINT OR TYPE
Name of Hospital                                                                                     Taxpayer Identification Number

Number & Street Address                                                                              Hospital Fiscal Year End Date

Address (continued)

City / Town                                                                     State              Zip Code + 4 (or Canadian Postal Code)
                                                                                 
STEP 2 - Type of Return (check if applicable)
  Initial Return (1st filing)       Amended Return               Final Return    Last Day of Business

STEP 3 - Calculate Your Balance Due or Overpayment                              Round to the nearest whole dollar
1. Gross Charges:
(a) Inpatient Hospital Services                                1(a) 
(b) Outpatient Hospital Services                               1(b)

          Total Gross Charges (Sum of Lines 1(a) and 1(b))                             1 

2. Net Excluded Charges for Outpatient Hospital Services from 'PSN %1     4$)  -JOF    2

3. Subtotal (Line 1 minus Line 2)                                                      3 

4. Deductions: 
(a) Bad Debts                                                              4(a) 
(b) Charity Care                                                           4(b) 

(c) Payor Discounts                                                        4(c)

          Total Deductions (Sum of Lines 4(a), 4(b), and 4(c))                         4 

5. Net Patient Services Revenue (Line 3 minus Line 4)                                  5 

6. New Hampshire Medicaid Enhancement Tax (Line 5 multiplied by applicable tax rate)             6 
7. Credits: 
(a) Credit Carryover from prior tax period                                 7(a) 
(b) Payment made with original return (Amended returns only)      7(b) 

          Total Credits (Sum of Lines 7(a) and 7(b))                                   7 

8. Balance of Tax Due (Line 6 less Line 7)                                             8 

DP-153  
7FSTJPO                                                                                                                                  1BHF   PG  

                    New Hampshire  
                      Department of                  DP-153                                    *0DP1532421862*
               Revenue Administration                                                                           0DP1532421862

                                       MEDICAID ENHANCEMENT TAX RETURN
STEP 3 - Calculate Your Balance Due or Overpayment - continued
9. Additions: 
(a) Interest                                                                        9(a) 
(b) Failure to Pay Penalty                                                          9(b) 

(c) Failure to File Penalty                                                         9(c) 

          Total Additions (Enter the sum of Lines 9(a), 9(b), and 9(c))                         9 

10. Balance Due (Line 8 plus Line 9)                                                           10 

11. Overpayment: Enter balance due if less than zero                                                   11
12. Apply overpayment to: 
(a) Credit - Next Year's Tax Liability                                          12(a) 

(b) Refund                                                                      12(b)

STEP 4 - Signatures
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 
person owning or operating the utility, this declaration is based on all information of which the preparer has knowledge.
Signature of Officer (in ink)                                                                            MMDDYYYY

Print Signatory Name & Title                                                                             Phone Number

Signature of Preparer                                                                                    MMDDYYYY

Printed Name of Preparer                                                                                 Preparer's Tax Identification Number

Preparer's Address                                                                                       Phone Number

Address (continued)

City / Town                                                                              State           Zip Code + 4 (or Canadian Postal Code)
                                                                                          
FILE ONLINE AT GRANITE TAX CONNECT                                                        Or mail to:    NH DRA 
                                                                                                                PO BOX 637 
                    HUD SFWFOVF OI HPW 5"1 @ 
                                                                                                                CONCORD NH 03302-0637

DP-153  
7FSTJPO        /202                                                                                                                            1BHF   PG