New Hampshire Installment Payment Agreement Coupon

Installment Payment Agreement Coupon
cd-404-2016_PRO.pdf
New Hampshire
Department of
Revenue Administration

Form CD-404
Installment
Payment
Agreement Coupon

Print Form
Reset Form
FOR DRA USE ONLY

INSTRUCTIONS
1 Select the tax type for which the payment applies.
2 For a Business Tax or Interest and Dividend Tax payment, select the appropriate entity type. For Meals and Rentals (M&R) Tax, Real Estate
Transfer Tax (RETT), Tobacco Tax, and Other, select All Entity Types.
3 Select the "Yes" or "No" box to indicate if the payment is for a Lien Fee.
4 Enter the beginning and ending date of the taxable period for which the payment applies.
5 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.
6 Enter the due date of Installment Agreement payment (refer to Installment Payment Agreement schedule)
7 Enter the payment amount.
8 Enter the taxpayer's name, address, phone number and e-mail address. For a Joint entity type, please enter the information for the primary filer.
Make your check payable to: STATE OF NEW HAMPSHIRE
Do not staple or tape the coupon and check together.
If you are making payments for multiple tax periods or multiple tax types, please provide a coupon 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.
Mail this coupon with your payment to:
NH DRA
COLLECTION DIVISION
PO BOX 454
CONCORD, NH 03302-0454
Or E-File your payments at www.revenue.nh.gov/
Need Help? Call the Department at (603) 230-5900, Monday through Friday, 8:00am - 4:30pm
DO NOT CUT

1 Tax Type

3 Lien Fee?

2 Entity Type
MMDDYYYY

4 Taxable period beginning:

Yes

No

MMDDYYYY

and ending:

5 Taxpayer Identification #

FEIN

DIN

SSN

License Number

Taxpayer Name
Last Name

7 Amount Paid

6 Due Date of Payment

8

MI

First Name

Business Name

Number & Street Address
Address (continued)
For DRA Use Only

City / Town
Phone Number

CD-404
Version 1 7/2014

State

Zip Code

Email Address

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