New Hampshire Certification Request Form

Certification Request Form
au-22-2024.pdf
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New Hampshire
Department of
Revenue Administration

Reset Form

*00AU222411862*

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CERTIFICATION REQUEST FORM
STEP 1 - BUSINESS INFORMATION

TYPE OR PRINT

BUSINESS NAME

TAXPAYER IDENTIFICATION NUMBER

MAILING ADDRESS

DEPARTMENT IDENTIFICATION NUMBER (DIN)

MAILING ADDRESS (CONTINUED)

NH SECRETARY OF STATE IDENTIFICATION NUMBER

STATE

CITY / TOWN

ZIP CODE

COMMUNICATIONS SERVICE TAX REGISTRATION NUMBER

EMAIL

MEALS & RENTALS TAX LICENSE NUMBER

1. Is certification letter to be sent to name and address above? If no, attach a Power of Attorney
(Form DP-2848) authorizing us to send to an address other than the business address above.
2. Email any communication regarding the AU-22 to the email address above?
3. Are you an LLC?

Yes

4. Entity Type (select one):

Yes

Yes

No

No

No
CORPORATION

PROPRIETORSHIP

PARTNERSHIP

FIDUCIARY

STEP 2 - REQUEST TYPE
Request Type:

STATEMENT OF GOOD STANDING

CERTIFICATE OF DISSOLUTION

STATEMENT FOR WITHDRAWAL

STEP 3 - INFORMATION
1. Date registered with Secretary of State's Office to conduct business in New Hampshire........................................................ 1
2. (a) Last day of business activity in New Hampshire................................................................................................................. 2a
(b) If this is a request for Withdrawal or Dissolution, has a final return encompassing the last day of business been
filed? If a final NH return has not been filed and is required, submit the final return with this request.

2b

Yes

3. Reason for request:

4. Which taxes have you filed with NH in the past? If you did not meet the filing requirement for any years, please see the
instructions. (Check all that apply and enter 4-digit year of the last return filed with the NH DRA.)
Interest and Dividends Tax

Real Estate Transfer Tax

Communications Services Tax

Business Taxes

Meals and Rentals Tax

Other

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New Hampshire
Department of
Revenue Administration

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CERTIFICATION REQUEST FORM (continued)
STEP 3 - INFORMATION (continued)
5. If filing as part of Combined Group indicate name and taxpayer identification number of company under which this entity files its NH returns:
TAXPAYER NAME

TAXPAYER IDENTIFICATION NUMBER

6. If requesting taxpayer is considered a disregarded entity for federal purposes (SMLLC), indicate name and taxpayer identification number of
company under which this entity reports its business activity federally:
TAXPAYER NAME

TAXPAYER IDENTIFICATION NUMBER

STEP 4 - ATTACHMENTS
1. Is the requesting company dissolving or liquidating? (If yes, see instructions.)

Yes

No

NOTE: The DRA has 60-days to respond for a Dissolution or Withdrawal and 30-days for a Good Standing.
2. A non-refundable fee of $30 made payable to the State of New Hampshire must be included with this
request. Requests submitted without the fee shall be denied.

Statement Request Fee $ 3 0

STEP 5 - SIGNATURE AND TITLE

DATE

SIGNATURE (IN INK)
PRINT SIGNATORY NAME
REQUESTOR NAME

TITLE
REQUESTOR TELEPHONE NUMBER

File online at Granite Tax Connect gtc.revenue.nh.gov/TAP/_/ or mail to NHDRA, PO Box 637, Concord NH 03302-3306.

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