New Hampshire Tax Appeal Form

Tax Appeal Form
A-101 Form
Print Form
FORM

NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION

A-101

APPEALS

STEP A
Print
or Type
NAME
ADDRESS
& ID
NUMBERS

Reset Form

LAST NAME

FIRST NAME & INITIAL

SOCIAL SECURITY NUMBER

SPOUSES LAST NAME

FIRST NAME & INITIAL

SOCIAL SECURITY NUMBER

BUSINESS NAME

FEDERAL IDENTIFICATION NUMBER

NUMBER & STREET ADDRESS

DEPARTMENT IDENTIFICATION NUMBER

ADDRESS (continued)

LICENSE NUMBER

CITY/TOWN, STATE & ZIP CODE

TELEPHONE NUMBER

REPRESENTATIVE’S NAME
REPRESENTATIVE’S TELEPHONE NUMBER

REPRESENTATIVE’S NUMBER & STREET ADDRESS
REPRESENTATIVE’S CITY/TOWN, STATE & ZIP CODE

STEP B
TAX YEAR
AND TAX
TYPE

TAX YEAR(S) _____________________ OR TAXABLE PERIOD BEGINNING _____________________ AND ENDING _____________________
Mo
Day
Year
Mo
Day
Year
TAX TYPE (CHECK BOX OR BOXES THAT APPLY)

BUSINESS TAX (BUSINESS PROFITS TAX OR BUSINESS ENTERPRISE TAX)

INTEREST & DIVIDENDS TAX

STEP C
FACTS &
ISSUES

STEP D
VALUE

UTILITY PROPERTY TAX

MEALS & RENTALS TAX

OTHER

REASON FOR APPEAL. SPECIFY THE CAUSE FOR APPEAL. Include all facts and applicable law. Attach additional sheets if necessary.

STATE YOUR OPINION OF VALUE. PROVIDE A DETAILED DESCRIPTION AND BASIS FOR THAT OPINION OF VALUE AND THE METHODOLOGY USED FOR YOUR DETERMINATION.

FOR UTILITY
PROPERTY TAX,
RAILROAD TAX
AND PRIVATE RAIL
CAR TAX APPEALS
ONLY

STEP E

ACTION
REQUESTED

REDETERMINE A TAX ASSESSMENT/BILL

RECONSIDER A DENIAL OF A REQUEST FOR REFUND

DISPUTE PENALTIES

DISPUTE INTEREST

OTHER _________________________________________________________________________________________________________________________

STEP F Enclose a copy of the Notice of Assessment or Letter of Denial. Appeal must be filed within 60 days after the issuance of the
REQUIRED Notice of Assessment or Denial. If a representative is being used, a Power of Attorney (POA) Form DP-2848, must be filed with the
DOCUMENTS Department of Revenue Administration.

Check this box if you have filed a Power of Attorney (POA), Form DP-2848 with the Department of Revenue Administration.

x

SIGNATURE OF TAXPAYER (IN INK)

DATE

SPOUSE’S SIGNATURE (IN INK)

DATE

SIGNATURE OF REPRESENTATIVE (IN INK)

DATE

NH DRA
MAIL HEARINGS BUREAU
109 PLEASANT STREET
TO:
PO BOX 1467
CONCORD, NH 03302-1467

A-101
Rev 1.1 1/2022