New Hampshire  
                                                       1":.&/5
                         Department of                                    *0NHPYT2411862*
                        Revenue Administration         706$)&3
                                                                             0NHPYT2411862

                                               (&/&3"- INSTRUCTIONS 

    Select the tax type for which the payment applies. 
    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.
    Enter the beginning and ending date of the taxable period for which the payment applies. 
    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.
    Enter the amount paid.
    Enter the taxpayer's name and address. For a joint entity type, please enter the information for the primary filer. 
M",& :063 $)&$, 1":"#-& 50: STATE OF NEW HAMPSHIRE 
%0 /05 45"1-& 03 5"1& 5)& 706$)&3 "/% $)&$, 50(&5)&3  
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. 

M"*- 5)*4 706$)&3 8*5) :063 1":.&/5 50 
NH DRA 
PO BOX 1265                                                       Pay online at Granite Tax Connect 
CONCORD, NH 03302-1265 
                                                                    HUD SFWFOVF OI HPW 5"1 @ 
Need Help?  Call the Department at (603) 230-5920, 
Monday through Friday, 8:00am - 4:30pm

  Tax Type                   Entity Type               %0 /05 $65

    Business                 Corporation       Combined    Partnership       Proprietorship     Fiduciary               Non-Profit
    Interest & Dividends     Individual/Joint  Partnership Estate

    .FBMT   3FOUBMT          All Entity Types
                             MMDDYYYY                             MMDDYYYY
   5BYBCMF QFSJPE CFHJOOJOH                            and ending:

   5BYQBZFS *EFOUJGJDBUJPO                                                                      Amount Paid
                             '&*/        SSN   %*N     M&R License  
  Taxpayer *OGPSNBUJPO
Last Name                                                         First Name                                                       MI

Business Name

Number & Street Address

Address (continued)

City / Town                                                       State      Zip Code + 4 (or Canadian Postal Code)
                                                                   
    1BZNFOU 7PVDIFS
    Version 1      /202                                                                                                 1BHF   PG