New Hampshire Disaster Relief Request

Disaster Relief Request
a_101.indd
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FORM

NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION

A-105

DISASTER RELIEF REQUEST

STEP A
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or Type
NAME
ADDRESS
& ID
NUMBERS

Reset Form

LAST NAME

FIRST NAME & INITIAL

SOCIAL SECURITY NUMBER

SPOUSE'S 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

PHONE NUMBER

STEP B
TAX YEAR
AND TAX
TYPE

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

OTHER ______________________________________________

STEP C
FACTS &
ISSUES

REASON FOR REQUEST. SPECIFY THE CAUSE OF EVENT:
HOSPITALIZATION

FIRE

DATE OF EVENT:

STORM

OTHER

CITY/TOWN OF EVENT LOCATION:

STATE WITH SPECIFICITY ALL OF THE REASONS FOR YOUR REQUEST. ATTACH ADDITONAL SHEETS IF NECESSARY.

STEP D
ACTION
REQUESTED

RECALCULATE A TAX ASSESSMENT/BILL

ABATE PENALTIES

ABATE INTEREST

OTHER __________________________________________________________________________________

STEP E
REQUIRED Enclose a copy of the Notice of Assessment or other Department notice that this relates to. In addition, submit supporting
DOCUMENTS documentation such as copies of hospital bills, insurance claims, or newspaper articles that confirm your disaster event.
Check this box if you have filed a Power of Attorney (POA), Form DP-2848 with the Department of Revenue Administration for
the above referenced tax period.

x
SIGNATURE OF TAXPAYER (IN INK)

DATE

SPOUSE'S SIGNATURE (IN INK)

DATE

MAIL NH DRA
109 PLEASANT STREET
TO:
PO BOX 637
CONCORD, NH 03302-0637

A-105
Version 1

02/2024

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