2021 DP-10 DP-10 2021 Version 1.4 09/2021 DO NOT STAPLE INTEREST AND DIVIDENDS TAX RETURN For the CALENDAR year 2021 or other taxable period beginning: MMDDYYYY and ending: MMDDYYYY STEP 1 - PRINT OR TYPE Check box if there has been a name change since last filing. Last Name First Name MI Social Security Number Spouse's Last Name First Name MI Social Security Number Due Date for CALENDAR year filers is on or before April 15, 2022. Due Date for FISCAL year filers is the 15th day of the 4th month after the close of the taxable period.

Taxpayer Identification Number Name of Partnership, Estate, or LLC Number & Street Address Address (continued) Unit Type Unit # City / Town State Zip Code + 4 (or Canadian Postal Code) STEP 2 - Return Type and Alternate Address ENTITY TYPE - Check One 1 - INDIVIDUAL 1 - JOINT 3 - PARTNERSHIP/LLC 4 - ESTATE % of NEW HAMPSHIRE Ownership Interest in Entity Type Tax Forms Mailing Address, City/Town, State & Zip Code INITIAL RETURN MMDDYYYY Established NH Residency FINAL RETURN MMDDYYYY Abandoned NH Residency AMENDED RETURN FINAL DECEASED Date of Death Social Security Number Page 1 of 5 Payment Required Refund Request Credit Next Year's Tax Liability No Payment Required Check Appropriate Box(es): If you have a DIN, use the DIN in the taxpayer ID box. DO NOT use FEIN or SSN IRS ADJUSTMENT: A complete federal Report of Change form with all applicable Schedules must be included with a complete amended NH tax return. Incomplete Report of Change forms will not be accepted. Do not use this form to report an IRS adjustments for taxable periods ending on or before December 31, 2020.

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              2021 DP-10 DP-10 2021 Version 1.4 09/2021 INTEREST AND DIVIDENDS TAX RETURN - continued STEP 3 - Read instructions before you begin INTEREST & DIVIDENDS FROM ALL SOURCES Round to the nearest whole dollar 1 From Your Federal Income Tax Return: (See Instructions) (a) Interest Income. Enter the amount from Line 2(b) of your federal return

1(a) (b) Dividend Income. Enter the amount from Line 3(b) of your federal return

1(b) (c) Federal Tax-Exempt Interest Income. Enter the amount from Line 2(a) of your federal return

1(c) (d) Subtotal Interest and Dividends Income. (Sum of Lines 1(a), 1(b) and 1(c))

Subtotal 1(d) 2 List Taxable Annuities or Actual Cash & Property Distributions From S-Corporations, Trusts/Estates, Partnerships, and LLCs: Entity Codes: 2 = S-CORPORATIONS; 3 = PARTNERSHIPS; 4 = TRUSTS OR ESTATES; 5 = LLC; 6 = FOUNDATIONS; 7 = OTHER I Entity Code II Name of Payor III Payor's ID Number IV Distribution Amount Total from supplemental schedule attached 2 Total Distributions (Sum of Column IV above)

2 3 Subtotal Gross Interest and Dividends Income and Distributions (Line 1(d) plus Line 2)

Subtotal 3 4 List payors and amounts of interest and/or dividends NOT TAXABLE to New Hampshire included on Lines 1(a), 1(b), 1(c) and/or 2: I Reason Code II Name of Payor III Payor's ID Number IV Non-Taxable Amount (a) Subtotal of non-taxable income above (Sum of Column IV) 4(a) (b) Total non-taxable income from supplemental schedule (Attached) 4(b) (c) Non-taxable income (Subtotal of Lines 4(a) plus 4(b))

4(c) (d) Part-year resident non-taxable income pro rata share

4(d) Page 2 of 5

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              2021 DP-10 DP-10 2021 Version 1.4 09/2021 INTEREST AND DIVIDENDS TAX RETURN - continued STEP 3 - (continued) Read instructions before you begin INTEREST & DIVIDENDS FROM ALL SOURCES Round to the nearest whole dollar 4 Total Non-Taxable Income (Sum of Line 4(c) plus Line 4(d))

4 5 Gross Taxable Income (Line 3 minus Line 4)

5 6 Less: $2,400 for Individual, Partnership and Estate; $4,800 for Joint filers

6 7 Adjusted Taxable Income (Line 5 minus Line 6) If less than zero, use minus sign.

7 Blind Spouse Blind 65 (or over) or disabled Year of Birth Spouse 65 (or over) or disabled Year of Birth 8 Check the exemptions that apply. Total number of boxes checked x $1200 =

8 9 Net Taxable Income (Line 7 minus Line 8). If less than zero, use minus sign.

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              2021 DP-10 DP-10 2021 Version 1.4 09/2021 INTEREST AND DIVIDENDS TAX RETURN - continued STEP 4 - Calculate Your Tax, Credits, Interest and Penalties Round to the nearest whole dollar 10 New Hampshire Interest and Dividends Tax (Line 9 multiplied by 5%)

10 13 Payments: (a) Tax paid with application for extension

13(a) (b) Current year estimated tax payments

13(b) (c) Credit carryover from prior tax period

13(c) 13 Subtotal of Lines 13(a) through 13(d) (d) Paid with original return (Amended returns only) 13(d) 14 Subtotal Due (Line 12 minus Line 13 Subtotal)

14 15 Additions to Tax: (a) Interest

15(a) (b) Failure to Pay

15(b) (c) Failure to File

15(c) 15 Subtotal of Lines 15(a) through 15(d) (d) Underpayment of Estimated Tax

15(d) STEP 5 - Calculate Your Net Balance Due or Overpayment 16 (a) Subtotal Due (Line 14 plus Line 15 Subtotal) 16(a) (b) Return Payment Made Electronically

16(b) 17 Net Balance Due (Line 16(a) minus Line 16(b)) (Make Check Payable to State of New Hampshire)

17 PAY THIS AMOUNT 18 OVERPAYMENT (If balance due is less than zero, enter on Line 18) 18 19 Amount of Line 18 to be applied to: (a) Credit - Next Year's Tax Liability (Not available for Federal ROC) 19(a) DO NOT PAY (b) Refund (Only option available for Federal ROC)

19(b) DO NOT PAY Page 4 of 5 11 RSA 77-G Education Tax Credit

11 12 New Hampshire Interest and Dividends Tax Net of Education Tax Credit (Line 10 minus Line 11. If negative enter zero)

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              2021 DP-10 DP-10 2021 Version 1.4 09/2021 INTEREST AND DIVIDENDS TAX RETURN - continued 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. POA: By checking this box and signing below, you authorize us to discuss this return with the preparer listed below. TAXPAYER'S SIGNATURE & INFORMATION Signature (in ink) MMDDYYYY If joint return, BOTH parties must sign, even if only one had income MMDDYYYY Print Signatory Name(s) (and Title if applicable) Taxpayer's Phone Number Filing as surviving spouse Form 1310 attached PAID PREPARER'S SIGNATURE & INFORMATION Signature of Preparer MMDDYYYY Printed Name of Preparer Preparer's Phone Number Preparer Identification Number Preparer's Address City / Town State Zip Code + 4 (or Canadian Postal Code) Page 5 of 5 Mail to: NH DRA PO Box 637 Concord NH 03302-0637 Make Check Payable to: STATE OF NEW HAMPSHIRE Enclose but DO NOT staple or tape your attachments FILE ONLINE AT GRANITE TAX CONNECT www.revenue.nh.gov/gtc

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