Form Dp-165 - Research And Development Tax Credit Application - 2011
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1FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
DP-165
RESEARCH & DEVELOPMENT TAX CREDIT APPLICATION
FOR DRA USE ONLY
Taxable period end date: ___________________________________ Date of Request: ________________________________
MONTH
DAY
YEAR
MONTH
DAY
YEAR
PRINT OR TYPE
5
1
NAME (PRINCIPAL NH FILER IF COMBINED GROUP):
FEDERAL IDENTIFICATION NUMBER:
5(a)
SOCIAL SECURITY NUMBER:
2
STREET ADDRESS:
5(b)
ADDRESS (CONTINUED):
DEPARTMENT IDENTIFICATION NUMBER:
3
CITY/STATE/ZIP:
4
CONTACT NAME & TITLE
TELEPHONE NUMBER:
6
Qualifi ed Manufacturing Research & Development expenditures (wages only) per Federal return..............................
Attach copy of Federal Form 6765, Credit for Increasing Research Activities
7
Qualifi ed Manufacturing Research & Development expenditures (wages only) attributable to NH................................
8
Amount of Research & Development Credit requested (Line 7 x 10%) not to exceed $50,000..................................
Do not submit this application without the Federal Form 6765.
SIGNATURE (IN INK)
DATE
MAIL TO:
NH DRA
PO BOX 488
PRINT SIGNATORY NAME & TITLE
CONCORD NH 03302-0488
DP-165
Rev 02/2011
INSTRUCTIONS
ABOUT THE RESEARCH & DEVELOPMENT TAX CREDIT
LINE 7
RSA 77-A:5, XIII allows for a Research & Development Credit for
Enter the amount of the Qualifi ed Manufacturing Research &
qualifi ed manufacturing research & development expenditures made
Development expenditures as defi ned in RSA 77-A:5, XIII(b)(1) that are
or incurred during the fi scal year of the company. The taxpayer
attributable to New Hampshire activities (wages only).
shall apply for this credit using the Research and Development Tax
LINE 8
Credit Application (Form DP-165) which shall be postmarked no later
than June 30 following the taxable period during which research
Enter the amount of Research & Development Credit requested by
and development expenditure was made or incurred. For additional
multiplying the New Hampshire Qualifi ed Manufacturing Research &
information, refer to TIR 2007-007, available on the NH DRA website at
Development expenditures by 10 percent (Line 7 x 10%), not to exceed
$50,000.
TAXABLE PERIOD END DATE
SIGNATURES
Include the taxable period end date of the company.
The application must be dated and signed in ink by the taxpayer or
authorized agent. In addition, print the name and title of the offi cer or
DATE OF REQUEST
authorized agent signing the application.
Enter the current date of the application.
Do not submit this application without the Federal Form
LINES 1 THROUGH 5
6765.
Enter the Principal Filer's Name, Address, the Contact Person's Name
WHERE TO MAIL
and Title, Federal Employer Identifi cation Number (FEIN), Social
Security Number (SSN), or Department Identifi cation Number (DIN) of
Mail to: NH DRA, PO Box 488, Concord, NH 03302-0488
the entity requesting the Research and Development Credit. Wherever
FEINs are required, taxpayers who have been issued a DIN shall use
their DIN only and not their FEIN.
LINE 6
Enter the amount of the Qualifi ed Manufacturing Research &
Development expenditures as defi ned in RSA 77-A:5, XIII(b)(1), and
reported on Line 5 the Federal Form 6765 (wages only). Attach a copy
of Federal Form 6765.
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