New Hampshire  
                   Department of                  ED-05
     Revenue Administration
                                                                                         FOR DRA USE ONLY
PRINT OR TYPE                      SCHOLARSHIP ORGANIZATION REPORT
                                                  This report is due on or before July 30

1. SCHOLARSHIP ORGANIZATION:

2. STREET ADDRESS:

   ADDRESS (CONTINUED):

3. CITY/STATE/ZIP:

This  Scholarship  Organization  Report  has  been  developed  by  the  Department  of  Revenue  Administration  for 
submission by a scholarship organization to the Department of Revenue Administration and shall be a public record, 
pursuant to RSA 77-G:1, XIX. 
  
Within  30  days  following  the  end  of  each  program  year,  the  scholarship  organization  shall  submit  a  Scholarship 
Organization Report to the Department of Revenue Administration. The scholarship organization shall also include a 
Scholarship Organization Application if the scholarship organization intends to issue scholarships under RSA 77-G in 
the next program year.

Under RSA 77-G the following data must be provided by each scholarship organization:

The number of scholarships granted to eligible students who are New Hampshire residents and who are at least 5 
years of age and no more than 20 years of age, have not graduated from high school, and who are currently attending 
a New Hampshire public school, including a chartered public school, for whom the adequacy grant in the next school 
year  would  be  reduced  if  the  student  were  removed  from  the  average  daily  membership  calculation,  or  who  are 
entering kindergarten or first grade, and whose annual household income is less than or equal to 300 percent of the 
federal poverty guidelines as updated annually in the Federal Register by the United States Department of Health and 
Human Services under the authority of 42 U.S.C. section 9902(2).  

1(a) Number of students ......................     Number of scholarships granted.......................

The percentage of these students who were eligible for the federal free and reduced-price meal program in the prior 
year.
   1(b) Percentage of students eligible......

The number of scholarships granted to eligible students who are New Hampshire residents and who are at least 5 
years of age and no more than 20 years of age, have not graduated from high school, and who received a scholarship 
in the prior program year and whose annual household income is less than or equal to 300 percent of the federal 
poverty guidelines as updated annually in the Federal Register by the United States Department of Health and Human 
Services under the authority of 42 U.S.C. section 9902(2).  

   2(a) Number of students ...................... Number of scholarships granted......................

The percentage of these students who were eligible for the federal free and reduced-price meal program in the prior 
year.

   2(b) Percentage of students eligible.....

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                   New Hampshire  
                   Department of                     ED-05
              Revenue Administration

                         SCHOLARSHIP ORGANIZATION REPORT (continued)

The number of scholarships granted to eligible students who are New Hampshire residents and who are at least 5 
years of age and no more than 20 years of age, have not graduated from high school,  and who do not qualify under 
the  above  paragraphs  (1)  or  (2),  and  whose  annual  household  income  is  less  than  or  equal  to  300  percent  of  the 
federal poverty guidelines as updated annually in the Federal Register by the United States Department of Health and 
Human Services under the authority of 42 U.S.C. section 9902(2). 

   3(a) Number of students .........................                    Number of scholarships granted..................
The percentage of these students who were eligible for the federal free and reduced-price meal program in the prior 
year.
   3(b) Percentage of students eligible.........

4(a)  The total dollar amount of donations received ........................................................                   $
4(b)  The total dollar amount carried forward from prior program year(s)........................                               $

4(c)  The total dollar amount of all scholarships granted ................................................                     $
4(d)  The total dollar amount of donations used for scholarships....................................                           $
4(e) The total dollar amount of donations spent on administrative expenses pursuant 
        to RSA 77-G:5, I(f) .................................................................................................. $
4(f)  The total dollar amount of donations not used for scholarships...............................                            $

4(g)  The total dollar amount of donations carried forward into next program year.........                                     $
5.    The total number of all scholarships granted ...........................................................                 $
6.    The total dollar amount of donations granted to home educated students...............                                    $

 7.    The number of scholarships distributed by the organization, per school, and the dollar range of those scholarships.  
        (All home educated students shall be totaled together as a single school.) If more than one school, attach additional  
        pages.
     (a) Number of Scholarships.........................................
     (b) Dollar range of Scholarships .................................                                                   to

8. List number of students receiving a scholarship under RSA 77-G by zip code:

     Number of Students           Zip Code                              Number of Students                                      Zip Code

9. (1) The aggregated results from the NH Education Tax Credit Survey designed by the Department of Revenue 
         Administration under RSA 77-G:1, XIX(k).
     (a) Number of participating students ............................................................................

     (b) Number of participating students whose parents/legal guardians were solicited ....

     (c) Percentage of participating students whose parents/legal guardians were solicited 

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                   New Hampshire  
                   Department of               ED-05
         Revenue Administration
                            SCHOLARSHIP ORGANIZATION REPORT (continued)
         (d) I am satisfied with the school my child is attending as compared to the school my child attended prior to the 
         availability of the education tax credit program. 
         Strongly Agree    Agree     No Change             Disagree                   Strongly Disagree
                   1       2                3                                    4    5

         (e) My child has seen a measurable improvement in academic achievement.
         Strongly Agree    Agree     No Change             Disagree                   Strongly Disagree
                   1       2                3                                    4    5

         (f) My child would have been unable to attend the school of his or her choice without the education tax credit 
         program.
         Strongly Agree    Agree     No Change             Disagree                   Strongly Disagree
                   1       2                3                                    4    5

     (2)  Excluding  the  Education  Tax  Credit  scholarship,  how  much  was  paid  out  of  pocket  for  children  in  the 
     program  to  attend  school  this  year?    (Do  not  include  fees  or  expenses  related  to  participation  in  athletic 
     programs, transportation expenses, extracurricular activities or clothing).

     (a) Total for all respondents.................................................  $

10.  The aggregated results from the survey designed by the Department of Education under RSA 77-G:1, XIX (l).

     (a) Number of surveys sent by the Scholarship Organization 

     (b) Number of respondents ..............................................

     (1)  Is  the  student  attending  a  private,  public,  community,  or  vocational  college,  or  otherwise  employed  or 
     unemployed?

     (a) Number attending a private college ............................
     (b) Number attending a public college .............................

     (c) Number attending a community college .....................
     (d) Number attending a vocational college ......................
     (e) Number employed ......................................................

     (f) Number unemployed ...................................................

     (2) How many students graduated?

     (a) Number graduated .......................................................

     (b) Number did not graduate ..............................................

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                   New Hampshire  
                   Department of           ED-05
     Revenue Administration
                               SCHOLARSHIP ORGANIZATION REPORT (continued)

11.  The number of participating students who graduated from high school in the previous year and the number that 
     dropped out of school.

     (a) Number graduated ........................................................

     (b) Number dropped out .....................................................

12.  Provide an explanation of information omitted from the report because it would reveal private data about an 
       individual student.

13(a) Provide the name of any other scholarship organizations who have agreed to combine their data with your 
    scholarship organization data for the purposes set forth in RSA 77-G:2, II. The agreement shall only be 
    considered valid if each scholarship organization lists the other scholarship organizations in the agreement.

13(b) If you have an agreement to combine data with another scholarship organization, does this report reflect the 
    combined data or just the data for the scholarship organization that prepared this report?

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.    I  do  hereby  attest  that  the  scholarship  organization  is  in  full 
compliance with the provisions of RSA 77-G, the Education Tax Credit statute.

AUTHORIZED SIGNATURE (IN INK)                                                     DATE

PRINT SIGNATORY NAME & TITLE

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

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