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

          ELECTRONIC  FUNDS TRANSFER A&+ &5(',7 5(*,675$7,21 )25 %86,1(66 7$; 3$<0(176

                                                          *(1(5$/ ,16758&7,216
 PRENOTE TEST                                                                    WHAT TO FILE
 $OO WD[SD\HUV SDUWLFLSDWLQJ LQ 1HZ +DPSVKLUH V $&+ &5(',7 SURJUDP DUH           $Q\ EXVLQHVV WD[SD\HU LQWHUHVWHG LQ PDNLQJ WD[ SD\PHQWV YLD $&+ 
 UHTXLUHG WR FRPSOHWH D VXFFHVVIXO 3UHQRWH 7HVW DW OHDVW    FDOHQGDU GD\V        &5(',7  PXVW VXEPLW WKLV IRUP WR UHJLVWHU DV DQ $&+ &5(',7 WD[SD\HU 
 SULRU WR WKH GXH GDWH RI WKHLU ILUVW $&+ &5(',7 SD\PHQW  'R QRW VHQG            ZLWK WKH 1HZ +DPSVKLUH 'HSDUWPHQW RI 5HYHQXH $GPLQLVWUDWLRQ  7KH 
 SD\PHQW YLD $&+ &5(',7 XQWLO \RX KDYH UHFHLYHG FRQILUPDWLRQ RI D                LQIRUPDWLRQ SURYLGHG RQ WKLV IRUP VKRXOG LQFOXGH WKH QDPH  DGGUHVV DQG 
 VXFFHVVIXO SUHQRWH                                                              WHOHSKRQH QXPEHU RI WKH SULPDU\ DQG VHFRQGDU\ FRQWDFW SHUVRQ V  IRU $&+ 
 1HZ +DPSVKLUH 'HSDUWPHQW RI 5HYHQXH $GPLQLVWUDWLRQ V %DQN $FFRXQW               &5(',7 SXUSRVHV  ,Q DGGLWLRQ  WKLV IRUP VKRXOG EH XVHG WR UHSRUW DQ\ 
 LQIRUPDWLRQ ZLOO EH SURYLGHG WR \RX DORQJ ZLWK WKH 'HSDUWPHQW V DSSURYDO IRU    FKDQJHV LQ \RXU UHJLVWUDWLRQ LQIRUPDWLRQ  L H   D FKDQJH LQ WD[SD\HU FRQWDFW  
 WKH 1HZ +DPSVKLUH ()7 $&+ &5(',7 SURJUDP                                        WHOHSKRQH QXPEHU  HWF   
 WHEN TO FILE                                                                    WHERE TO FILE
 7KLV IRUP PXVW EH ILOHG DW OHDVW    GD\V SULRU WR WKH GXH GDWH RI \RXU ILUVW    New Hampshire Department of Revenue Administration, Taxpayer 
 $&+ &5(',7 SD\PHQW  $Q\ FKDQJHV LQ WKH UHJLVWUDWLRQ LQIRUPDWLRQ PXVW EH         Services Division, PO Box 637, Concord, NH 03302-0637.
 SURYLGHG WR WKH 'HSDUWPHQW DW OHDVW    GD\V SULRU WR WKH FKDQJH  $Q\ 
 FKDQJHV RI ILQDQFLDO LQVWLWXWLRQ DQG FRQWDFWV UHTXLUH DGGLWLRQDO SUHQRWH WHVWV  NEED HELP?
                                                                                 &DOO 7D[SD\HU 6HUYLFHV DW                 0RQGD\ WKURXJK )ULGD\  
 WHO &$1 FILE                                                                        DP     SP  +HDULQJ RU VSHHFK LPSDLUHG LQGLYLGXDOV PD\ 
 7KH 1HZ +DPSVKLUH $&+ &5(',7 SURJUDP LV OLPLWHG WR ILOHUV PDNLQJ                FDOO 7'' $FFHVV  5HOD\ 1+ DW                  
 SD\PHQWV IRU %XVLQHVV (QWHUSULVH 7D[ DQG %XVLQHVV 3URILWV 7D[ OLDELOLWLHV  

35,17 25 7<3(
5axpayer First Name                                  Taxpayer Last Name                                  Taxpayer Identification Number

Business Name
                                                                                                                DIN            FEIN    SSN

Number and Street Address

Address Continued

City/Town                               4UBUF        Zip/Postal Code
                                         
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 NumbeSSecondary Contact Fax Number

Please check one of the following:      New Registration            Change Request
ENTITY TYPE (Check one of the following):               NOTE:  If you are ILOLQJ DV a Combined group, you must check Combined *URXS  
  Corporation-2               Combined Group-6            Fiduciary-4            NRQ Profit-5 ParWnership-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. 

                              Reset Form

                                                                                                                                       DP-175
                                                                                                                                      9HUVLRQ