Form Dp-10 - Interest And Dividends Tax Return 1999 Page 2
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1
2FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
DP-10
REPORT OF INTEREST AND DIVIDENDS INCOME
TAX YEAR 1999
1
From Your Federal 1040 Income Tax Return: (Partnerships and Fiduciaries, see Instructions)
(a) Interest Income. Enter the amount from line 8(a)....................................................................1(a)
(b) Dividend Income. Enter the amount from line 9......................................................................1(b)
(c)
Federal Tax Exempt Interest Income. Enter the amount from line 8(b)..................................1(c)
2
List Payments From S-Corporations, Partnerships, and Fiduciaries: See instructions
Entity codes: 2=”S” or other Corporations; 3=Partnerships; 4=Trusts or Estates; 5=Other
(A)
(B)
(C)
(D)
ENTITY
PAYER’S IDENTIFICATION
DISTRIBUTION
NAME OF
CODE
PAYER
AMOUNT
NUMBER
Total from supplemental schedule attached
2 Total Distributions......................................................................................................................... 2
3 Subtotal Sum of lines 1(a), 1(b), 1(c) and 2.................................................................................. 3
4 List payers and amounts of interest and/or dividends NOT TAXABLE to NH included on
lines 1(a), 1(b), 1(c), and/or 2:
(See instructions)
(A)
(B)
(C)
(D)
REASON
NAME OF
NON-TAXABLE
PAYER’S IDENTIFICATION
AMOUNT
CODE
PAYER
NUMBER
Total from supplemental schedule attached
4 Total Non-Taxable Amount..................................................................................................... 4
5 Gross Taxable Income
( Line 3 minus line 4).
5
ENTER THIS AMOUNT ON PAGE 1, LINE 6......
DP-10
(2)
Rev. 12/99
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