Form Dp-10 - Interest And Dividends Tax Return 1999
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1
2NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
FORM
INTEREST AND DIVIDENDS TAX RETURN
DP-10
041
1999
For the CALENDAR year
or other tax year beginning
and ending
Mo
Day
Year
Mo
Day
Year
FOR DRA USE ONLY
Due Date for CALENDAR year is on or before April 18, 2000 or the 15th day of the 4th month after the close of the fiscal period.
L AST NAME
FIRST NAME & INITIAL
SSN
STEP 1
Please Print
SPOUSE’S LAST NAME
FIRST NAME & INITIAL
or Type
SPOUSE’S SSN
NUMBER AND STREET ADDRESS
FEIN ( Partnership or Fiduciary)
CITY OR TOWN, STATE AND ZIP CODE
STEP 2
1
1
3
INDIVIDUAL OR
JOINT
PARTNERSHIP
4
FIDUCIARY
% of NH Ownership
Entity Type
Check here if you would like your forms mailed to an address other than the above. (See instructions)
and Mailing
Information
Number and Street Address
City/Town
State
Zip
STEP 3
INITIAL RETURN: Date established residency...........................................................................................
Special
Mo
Day
Year
FINAL RETURN: Date abandoned residency.............................................................................................
Return Type
Mo
Day
Year
FINAL RETURN: Deceased taxpayer: Social Security #
Date of death
Mo
Day
Year
AMENDED RETURN: DO NOT use this form to report an IRS adjustment . See instructions.
STEP 4
COMPLETE NUMBERS 1 - 5 ON PAGE 2 BEFORE COMPUTING TAX
6 Gross Taxable Income (Page 2, line 5) ..............................................................................................6
STEP 5
Figure Your
7 Less: $2,400 Individual, Partnership, and Fiduciary; $4,800 Joint ................................................. 7
Net Taxable
8 Adjusted Taxable Income (Line 6 less line 7) .................................................................................... 8
Income
For Individual/Joint filers only: If line 8 is zero or less, you are not required to file.
However, to be removed from our mailing list check here and mail in the return..............................................
9 Deduction for Contribution to Qualified Investment Capital Company (see instructions)........... 9
10 Check the exemptions that apply
Blind
Spouse Blind
65 (or over) ____________ or disabled
Spouse 65 (or over) ____________ or disabled
Year of Birth
Year of Birth
Total number of boxes checked ___________________ x $1,200= __________________
10
11 Net Taxable Income (Line 8 less lines 9 and 10) ......................................................................... 11
STEP 6
12 New Hampshire Interest and Dividends Tax (Line 11 x 5%) .................................................... 12
Figure Your
13 Payments: (a) Tax paid with Application for Extension ..................... 13(a)
Tax, Credits,
Interest and
(b) Payment from 1999 Declaration of Estimated Tax ... 13(b)
Penalties
(c) Credit carryover from prior years ................................ 13(c)
(d) Paid with original return (Amended returns only)..... 13(d)
13
14 Balance of Tax Due (Line 12 less line 13) ..................................................................................... 14
15 Additions to Tax: (a) Interest
15(a)
(See instructions) .....................................................
(b) Failure to Pay
15(b)
(See instructions) .......................................
(c) Failure to File
15(c)
(See instructions) ........................................
(d) Underpayment of Estimated Tax
15(d)
15
(See instructions)
STEP 7
16 Total Balance Due (Line 14 plus line 15)
.......................... 16
Make check payable to: State of New Hampshire.
Enclose, but do not staple or tape, your payment with this return.
Balance
17 OVERPAYMENT (Line 13 less line 12 adjusted by line 15, if applicable)17
Due or
Overpayment
18 Amount of line 17 to be applied to:
(a)
..........18(a)
Your 2000 tax liability............................................
(b)
8(b)
FOR DRA USE ONLY
Refund - Please allow 12 weeks for processing................1
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.
Signature
Date
Signature of Paid Preparer Other Than Taxpayer
If joint return, BOTH husband and wife must sign, even if only one had income.
Date
Preparer’s Identification Number
Date
NH DEPT OF REVENUE ADMINISTRATION
Preparer’s Address
MAIL
DOCUMENT PROCESSING DIVISION
PO BOX 2072
TO:
CONCORD NH 03302-2072
City or Town, State, and Zip Code
DP-10
(1)
Rev. 12/99
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