New Hampshire  2019 and 2020 
                   Department of  
     Revenue Administration       ED-05
                                                                                    FOR DRA USE ONLY
PRINT OR TYPE                      SCHOLARSHIP ORGANIZATION REPORT
                                  This report is due on or before July 30, 2020

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 .........................................

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 ...........................................

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           2019 and 2020 
                   Department of  
              Revenue Administration                                ED-05

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

5.    The total dollar amount of all scholarships granted ..................................................                     $
6.    The number of scholarships granted ........................................................................
 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            2019 and 2020 
                   Department of  
         Revenue Administration                ED-05
                            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  2019 and 2020 
                   Department of  
     Revenue Administration                ED-05
                               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 457
                                           CONCORD NH  03302-0457

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