New Hampshire  
                          Department of                 ED-01
                     Revenue Administration                                                                    FOR DRA USE ONLY
                                         SCHOLARSHIP ORGANIZATION APPLICATION
      PRINT OR TYPE                      This application is due no later than June 15. 
      STEP 1
   1. ORGANIZATION NAME:                                    5. FEDERAL TAXPAYER IDENTIFICATION NUMBER:

   2. STREET ADDRESS:

      ADDRESS (CONTINUED):

   3. CITY/STATE/ZIP:

   4. ORGANIZATION CONTACT NAME & TITLE:                       TELEPHONE NUMBER:

      EMAIL ADDRESS:

      STEP 2

      I attest that the applying organization meets the following eligibility requirements of RSA 77-G:1, XVII:
   
      • The organization is a charitable organization incorporated or qualified to do business in New Hampshire; 
      • The organization is exempt from federal income taxation pursuant to section 501(c)(3) of the Internal Revenue Code 
        (Attach a copy of the organization's Section 501(c)(3) Exemption Determination Letter from the IRS); 
      • The organization complies with applicable state and federal antidiscrimination and privacy laws; 
      • The organization is registered with the New Hampshire Director of Charitable Trusts (Attach a copy of the 
        Certificate of Registration); 
      • The organization will comply with all of the provisions of RSA 77-G. 

   Under penalties of perjury, I declare that I have examined this document and to the best of my belief the information herein
   is true, correct and complete. Further, I attest to the eligibility requirements listed in Step 2 above.

      AUTHORIZED SIGNATURE (IN INK)                         DATE

      PRINT SIGNATORY NAME & TITLE

                                         MAIL TO: NH DRA
                                                  EDUCATION TAX CREDIT
                                                  PO BOX 637
                                                  CONCORD NH  03302-0637

 ED-01
 Version 1.3 09/2022

                   New Hampshire  
                   Department of                         ED-01
                   Revenue Administration
                     SCHOLARSHIP ORGANIZATION APPLICATION INSTRUCTIONS

WHO MUST FILE?                                           LINE-BY-LINE INSTRUCTIONS  
Non-profit  entities  wishing  to  become  qualified       
scholarship  organizations  must  file  a  Scholarship   STEP 1 
Organization Application (Form ED-01).                     
                                                         LINE 1  
WHEN TO FILE?                                            Enter the organization's name. 
Form  ED-01  must  be  received  by  the  Department  of   
Revenue Administration no later than June 15 in the      LINE 2  
program year.                                            Enter the organization's street address. 
                                                           
WHERE TO FILE? 
                                                         LINE 3  
Form ED-01 may be mailed to:                             Enter the organization's city, state and zip code. 
                                                           
NH DRA                                                   LINE 4  
Education Tax Credit                                     Enter the name, title, telephone number and email 
PO Box 637                                               address of the contact person for the organization.  
Concord, NH 03302-0637                                   The contact person should be the person the 
                                                         Department of Revenue Administration can contact 
Or may be hand-delivered to the Department of            regarding this application. 
Revenue Administration during business hours               
(Monday through Friday, 8:00 a.m. to 4:30 p.m.) at:      LINE 5  
                                                         Enter the organization's Federal Taxpayer 
Governor Hugh J. Gallen Office Park South                Identification Number. 
109 Pleasant Street                                        
Medical and Surgical Building                              
Concord, NH 03301                                        STEP 2 
 NEED HELP?                                                
Call the Department at (603) 230-5920, Monday            The authorized signer shall read all of the statements 
through Friday, 8:00am to 4:30pm. For more               contained in the application and affirm them to be 
information visit us on the web at: www.revenue.nh.      true for the applying organization.  This affirmation 
gov. Hearing or speech impaired individuals may call     shall be evidenced by signing the application as 
TDD Access: Relay NH 1-800-735-2964.                       stated below.
                                                           
                                                         The application must be dated and signed in ink by 
                                                         an  officer  or  authorized  agent.  In  addition,  print  the 
                                                         name  and  title  of  the  officer  or  authorized  agent 
                                                         signing the application. 
                                                           
                                                         NOTICE 
                                                         Do not submit this application without including 
                                                         a copy of the organization's Section 501(c)(3) 
                                                         Exemption Determination Letter from the Internal 
                                                         Revenue Service and a copy of the organization's 
                                                         Certificate of Registration from the New 
                                                         Hampshire Charitable Trust Unit.

ED-01
Version 1.3 09/2022