Form Rsa 78-B Real Estate Transfer Tax Declaration Of Consideration

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NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
REAL ESTATE TRANSFER TAX
CD-57
DECLARATION OF CONSIDERATION
(RSA 78-B)
PLEASE PRINT OR TYPE
STEP 1
LAST NAME OR ENTITY
FIRST & INITIAL
FEIN OR SSN
Purchaser
Grantee
LAST NAME OR ENTITY
FIRST & INITIAL
FEIN OR SSN
Assignee
Transferee
NUMBER & STREET ADDRESS
ADDRESS (CONTINUED)
CITY/TOWN, STATE & ZIP CODE
,
LAST NAME OR ENTITY
FIRST & INITIAL
FEIN OR SSN
STEP 2
Seller
Grantor
LAST NAME OR ENTITY
FIRST & INITIAL
FEIN OR SSN
Assignor
Transferor
NUMBER & STREET ADDRESS
ADDRESS (CONTINUED)
CITY/TOWN, STATE & ZIP CODE
,
MUNICIPALITY
STEP 3
Real
Estate
BOOK NO.
PAGE NO.
COUNTY
Property
BRIEF DESCRIPTION: (SUCH AS MAP AND LOT NUMBERS; LOCATED AT 17 ELM STREET, AUBURN, OR 10 ACRES, FARM HOUSE AND BARN KNOWN AS SMITH
FARM, MILL ROAD, MILTON.)
,
STEP 4
Transfer
__
DATE OF TRANSFER:
MONTH
DAY __
YEAR __
Date
STEP 5
Purchaser
Seller
Figure
(a) FULL PRICE OR CONSIDERATION FOR THE REAL ESTATE
The
$
0.00
$
0.00
Tax
(b) ROUND LINE 5(a) UP TO THE NEAREST $100……………………..
$
0.00
$
0.00
(c) DIVIDE LINE 5(b) BY $100……………………………………………
$
0.00
$
0.00
$
$
(d) TAX RATE PER $100 AT TIME OF TRANSFER (See Instructions)
.75
.75
$
$
0.00
0.00
(e) SUBTOTAL OF TAX [Line 5(c) multiplied by 5(d)] …………………..
(f) TOTAL TAX PAID TO COUNTY………………………………………...
0.00
$
(Sum of purchaser & seller subtotals rounded to the nearest whole dollar) DO NOT MAIL PAYMENT WITH THIS FORM.
STEP 6
Were there any special circumstances in the transfer which suggest that the full price or consideration of the property was either
Special
more or less than its fair market value?
NO
YES, if yes, please explain.
Circumstances
STEP 7
Under penalties of perjury, I declare that I have examined this document and to the best of my belief it is true, correct and
Signatures
complete.
FOR DRA USE ONLY
PURCHASER'S SIGNATURE (IN INK)
DATE
SELLER'S SIGNATURE (IN INK)
DATE
PURCHASER'S SIGNATURE (IN INK)
DATE
SELLER'S SIGNATURE (IN INK)
DATE
PURCHASER'S SIGNATURE (IN INK)
DATE
SELLER'S SIGNATURE (IN INK)
DATE
WITNESS SIGNATURE (IN INK)
DATE
WITNESS SIGNATURE (IN INK)
DATE
MAIL
NH DEPT OF REVENUE
CD-57
TO:
ADMINISTRATION
Rev 4/02
45 CHENELL DRIVE, PO BOX 1324
CONCORD NH 03302-1324

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