New Hampshire Requesting an Installment Payment Agreement

Requesting an Installment Payment Agreement
cd-400-2023.pdf
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New Hampshire
Department of
Revenue Administration

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CD-400

REQUEST FOR INSTALLMENT PAYMENT AGREEMENT
This request is for :
Tax Type:

Business

Interest and Dividends

Meals & Rentals

Taxable Period(s) Beginning :

and Ending:

Beginning :

and Ending:

Other (Specify):

Upon the approval of this agreement, I agree to waive any existing appeal rights and/or
withdraw any existing appeals for the tax type(s) and taxable periods(s) stated above.
Taxpayer Identification #:

FEIN

DIN

Yes

No

Not Applicable

License #:

SSN

Taxpayer Name:
Mailing Address:
State:

City:
Daytime Telephone Number:

Zip Code:
New Address?

Yes

No

Name of Bank:

Enter the total amount owed:

$

Enter the amount of payment enclosed:

$

Enter the amount you are able to pay each month:

$

Make your payments as large as possible to limit interest charges.
Save postage and interest by accessing our website at: gtc.revenue.nh.gov/TAP/_/ and make each payment by authorizing withdrawal
of the payment from your account.
Select the date payments will be made each month. You cannot select a date later than the 28th.

I understand that submitting an Installment Payment Agreement Request is a declaration of an inability to pay taxes owed to the Department in full
within the next 30 days. The Department may require further information to verify this is a genuine attempt to satisfy the tax obligation owed to the
Department in a timely and reasonable manner. I declare that I am authorized to request an Installment Payment Agreement for the taxpayer named
above.
Signature

Print Name

CD-400
Version 2 07/2024

Date

Title

Please complete this application and return with the first
proposed installment to:
NHDRA - Collections Division
PO BOX 454
CONCORD, NH 03302-0454

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