New Hampshire
                                                                   202  
                           Department of                                                *0DP59A2411862*
                        Revenue Administration                     DP-59-A                               0DP59A2411862

                                          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 
                                                                                                      HUD SFWFOVF OI HPW 5"1 @ 
For the CALENDAR year 202  or other taxable period beginning:
                                                                                        ENTITY TYPE - Check One
MMDDYYYY                                      MMDDYYYY
                                                                                        Individual/Joint       Partnership/LLC    Estate
                                   and ending:

Last Name

First Name                                         MI                Social Security Number                    Taxpayer Identification Number

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

Name of Partnership, Estate, or LLC

Number & Street Address

Address (continued)

City / Town                                                                      State      Zip Code + 4 (or Canadian Postal Code)
                                                                                  
100% PAYMENT IS DUE ON OR BEFORE THE DUE DATE OF THE TAX                                                                       306/% 50 5)& /&"3&45 8)0-& %0--"3
File online at Granite Tax Connect        1        Enter 100% of the Interest and Dividends Tax determined to be due (net of   
    HUD SFWFOVF OI HPW 5"1 @                  RSA 77-G Education Tax Credit)
                                          2(a)   Enter credit carried over from prior   
Make check payable to:                        year and total estimated tax payments
         State of New Hampshire     
Mail to: NH DRA                           2(b)   Enter payment previously made,  
        PO BOX 1265                                   if applicable
        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))
        payment to this extension.        3        NET BALANCE DUE:  
  If negative or zero DO NOT file this               (Line 1 minus Line 2)                  1": 5)*4 ".06/5
               application.

    DP-59-A  202  
    Version 1       /202                                                                                                          Page 1 of