New Hampshire Report of Change (ROC) Interest and Divideds

Report of Change (ROC) Interest and Divideds
DP-87 ID Form
FORM

NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION

FOR DRA USE ONLY

INTEREST AND DIVIDENDS TAX
REPORT OF CHANGE FOR IRS ADJUSTMENT ONLY

DP-87 ID
045

For the CALENDAR year

_____ or other taxable period beginning

Print Form

and ending
Mo

Day

Year

Mo

Day

Reset Form

Year

STEP 1

LAST NAME

FIRST NAME & INITIAL

TAXPAYER IDENTIFICATION NUMBER

Print or
Type

SPOUSE’S LAST NAME

FIRST NAME & INITIAL

TAXPAYER IDENTIFICATION NUMBER
TAXPAYER IDENTIFICATION NUMBER

NAME OF PARTNERSHIP OR FIDUCIARY
NUMBER & STREET ADDRESS
ADDRESS (Continued)
CITY/TOWN, STATE & ZIP CODE+4

STEP 2
Entity
Type
STEP 3
IRS
Adjustments

1 INDIVIDUAL
1 JOINT
1

3 PARTNERSHIP
4 FIDUCIARY

}

% of NEW HAMPSHIRE
Ownership Interest

FROM YOUR FEDERAL INCOME TAX RETURN : As originally filed or previously adjusted
(a) INTEREST INCOME [from DP-10, Page 2, Line 1(a)] .........................................................................1(a)
(b) DIVIDEND INCOME [from DP-10, Page 2, Line 1(b)]..........................................................................1(b)
(c) FEDERAL TAX EXEMPT INTEREST INCOME [from DP-10, Page 2, Line 1(c)] ................................1(c)
(d) SUBTOTAL INTEREST AND DIVIDEND INCOME [Sum of Lines 1(a), 1(b) and 1(c)] .......................1(d)

2

TOTAL DISTRIBUTIONS[as originally filed or previously adjusted [from DP-10, Page 2, Line 2] ................ 2

3

SUBTOTAL INTEREST & DIVIDENDS INCOME AND DISTRIBUTIONS as adjusted line 1(d) plus Line 2 ........ 3

4

INTERNAL REVENUE SERVICE ADJUSTMENTS TO FEDERAL INCOME :........................................... 4
(a) AMOUNT OF CHANGE TO INTEREST INCOME from Page 2, Section 1, Line 1 .............................4(a)
(b) AMOUNT OF CHANGE TO DIVIDEND INCOME from Page 2, Section 2, Line 2. ...........................4(b)
(c) AMOUNT OF CHANGE TO FEDERAL EXEMPT INTEREST INCOME from Page 2, Section 3, Line 3 .... 4(c)
(d) AMOUNT OF CHANGE TO OTHER INCOME from Page 2, Section 4, Line 4 ................................4(d)
(e) SUBTOTAL combine Lines 4(a), 4(b), 4(c) and 4(d) ...........................................................................4(e)

5

Subtotal Interest & Dividend Income and Distribution as adjusted by IRS adjustments
Line 3 adjusted by Line 4(e).......................................................................................................................... 5

6

TOTAL NON-TAXABLE INCOME as originally filed or previously adjusted (from DP-10, Pg 2, Line 4) .... 6

7

GROSS TAXABLE INCOME AS ADJUSTED BY IRS ADJUSTMENTS (Line 5 minus Line 6) ............... 7

8

LESS: $2,400 for Individual, Partnership and Fiduciary; $4,800 for Joint filers .......................................... 8

9

ADJUSTED TAXABLE INCOME (Line 7 minus Line 8). If negative show in parenthesis .......................

10

9

CHECK THE EXEMPTIONS THAT APPLY.
Blind

Spouse Blind

65 (or over) or disabled
Year of birth _________

Spouse 65 (or over) or disabled
Year of birth _________

Multiply the total number of boxes checked above _________ x 1,200 =
11 NET TAXABLE INCOME (Line 9 minus Line 10) If less than zero, enter amount in parenthesis ............. 11
STEP 4
Figure
Your Tax,
Interest
and
Penalties

FOR DRA USE ONLY

12

NEW HAMPSHIRE INTEREST AND DIVIDENDS TAX AS ADJUSTED BY IRS ADJUSTMENTS
(Line 11 multiplied by 5%) ........................................................................................................................... 12

13

NEW HAMPSHIRE INTEREST AND DIVIDENDS TAX as originally filed or previously adjusted ............ 13

14

BALANCE OF TAX DUE (Line 12 minus Line 13) .......................................................................................14

15

INTEREST DUE (see DP-87 instructions) .................................................................................................. 15

16

BALANCE DUE (Line 14 plus Line 15) (If less than $1.00 do not pay) .. PAY

17

REFUND DUE (Line 13 adjusted by Line 12) ............................................................................................. 17

THIS AMOUNT ....16

Under penalties of perjury, I declare that I have examined this return and to the best of my belief it is true, correct and complete. (If
prepared by a person other than the taxpayer, this declaration is based on all information of which the preparer has knowledge.)

x
x

POA: By checking this box and signing below, you authorize us to discuss this return with the preparer listed below.

Signature (in ink) AND TITLE IF FIDUCIARY

Date

Signature (in ink) of Paid Preparer Other Than Taxpayer

If joint return, BOTH parties must sign, even if only one had income

Date

Print Preparer’s Name & Tax Identifi cation Number

NH DRA
MAIL TAXPAYER SERVICES
TO: PO BOX 3306
CONCORD NH 03302-3306

Date

Preparer’s Address
City/Town, State & Zip Code+4

Do not use this form for adjustments made for taxable periods ending after December 31, 2020

DP-87 ID
Rev 09/2021

NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION

FORM

DP-87 ID

INTEREST AND DIVIDENDS TAX
REPORT OF CHANGE FOR IRS ADJUSTMENT ONLY
Page 2

SECTION 1 IRS ADJUSTMENTS TO INTEREST INCOME.
If the number of adjustments exceed the lines provided, attach a schedule and summarize on Line E
ADJUSTMENT DESCRIPTION

REPORTED

AMOUNT
OF CHANGE

BALANCE
AFTER CHANGE

AMOUNT
OF CHANGE

BALANCE
AFTER CHANGE

AMOUNT
OF CHANGE

BALANCE
AFTER CHANGE

A
B
C
D
E

Total from attached schedule

Line 1 Enter total of Lines A through E here and on Page 1, Line 4(a) .........................................................1
SECTION 2 IRS ADJUSTMENTS TO DIVIDEND INCOME.
If the number of adjustments exceed the lines provided, attach a schedule and summarize on Line E
ADJUSTMENT DESCRIPTION

REPORTED

A
B
C
D
E

Total from attached schedule

Line 2 Enter total of Lines A through E here and on Page 1, Line 4(b) .........................................................2
SECTION 3 IRS ADJUSTMENTS TO FEDERAL EXEMPT INTEREST INCOME.
If the number of adjustments exceed the lines provided, attach a schedule and summarize on Line E
ADJUSTMENT DESCRIPTION

REPORTED

A
B
C
D
E

Total from attached schedule

Line 3 Enter total of Lines A through E here and on Page 1, Line 4(c) .........................................................3
SECTION 4 IRS ADJUSTMENTS TO OTHER INCOME SUBJECT TO INTEREST AND DIVIDENDS TAX (see instructions).
If the number of adjustments exceed the lines provided, attach a schedule and summarize on Line E
ADJUSTMENT DESCRIPTION

REPORTED

AMOUNT
OF CHANGE

BALANCE
AFTER CHANGE

A
B
C
D
E

Total from attached schedule

Line 4 Enter total of Lines A through E here and on Page 1, Line 4(d) .........................................................4

DP-87 ID
Rev 09/2021