Form Mfd 1-S/af - Distributor Report Motor Fuel And Aviation - Departament Of Safety Road Toll Bureau, State Of New Hampshire Page 2

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STATE OF NEW HAMPSHIRE-MOTOR FUEL AND AVIATION DISTRIBUTOR REPORT INSTRUCTIONS

This form is to be used to report automotive gasoline, undyed special fuel, aviation gasoline and jet fuel transactions.

COMPLETE A SEPARATE

SCHEDULE FOR EACH PRODUCT TYPE & REPORT WHOLE GALLONS ONLY!

If there were no transactions for the reporting month, write ‘none’ on

lines 9, 19, and 27. The following items must be completed: The month and year for which the report is filed, the distributor name, NH license number,

mailing address, telephone number, signature, and title of authorized person and the date signed.

RSA 259:58 Motor Fuel “Motor Fuel” shall mean all products used in an internal combustion engine for the generation of power to propel motor vehicles

or mechanical contrivances on or over the ways of this state.”

RSA 259:37-b Gasoline “Gasoline” shall mean all products commonly or commercially known or sold as gasoline, including casinghead and absorption of

natural gasoline, regardless of their classification or uses, and any liquid prepared, advertised, offered for sale, or sold for use as or commonly and

commercially used as a fuel in internal combustion engines…”

RSA 259:103-a Special Fuel “Special Fuel” shall mean all products, except gasoline, propane, natural gas, or liquified natural gas, used in an internal

combustion engine for the generation of power to propel motor vehicles or mechanical contrivances on or over the ways.”

RSA 422:34 Airways Toll

I.”There is hereby imposed an airways toll of $.04 per gallon upon the sale of each gallon of motor fuel or fuel, as defined by RSA 259:58, sold to and used

in the propulsion of aircraft. The airways toll shall be subject to the exemptions provided for government sales by RSA 260:32.

II.

There is hereby imposed an airways toll of $.02 per gallon on the sale of each gallon of aviation jet fuel sold and used in the propulsion of

aircraft. All aircraft, however, that are certified to operate under part 121 of the rules and regulations of the Federal Aviation Administration shall

pay an airways toll of $.005 per gallon on aviation jet fuel sold and used in the propulsion of aircraft.”

INVENTORIES AND RECEIPTS

in transit & in NH

LINE 1

Enter the physical quantity of motor fuel and/or aviation fuel gallons contained

wholesale bulk storage at month’s

does not

beginning. This

include any product contained in a facility which is attached to a pump used for ‘retail’ sale to the public; or

product on consignment to a retail dealer or in a retail station.

LINE 2

Enter only receipts

into NH

wholesale bulk storage

from outside NH

and complete Schedule 2.

into NH

from NH

LINE 3

Enter only receipts

wholesale bulk storage

and complete Schedule 3.

outside NH

LINE 4

Enter only purchases of fuel shipped directly to customers

that did not enter your NH wholesale bulk storage and complete

Schedule 4.

in NH

LINE 5

Enter only purchases of fuel shipped directly to customers

that did not enter your NH wholesale bulk storage and complete Schedule

(from NH

LINE 6

List any inventory transfers and adjustments

wholesale bulk storage) of Undyed Special Fuel and complete Schedule 6.

LINE 7

Enter total gallons calculated from lines 1 through 6.

LINE 8

Enter the physical quantity of motor fuel and/or aviation fuel gallons contained

in transit & in NH

wholesale bulk storage at month’s end.

LINE 9

Enter the total gallons calculated from line 7 less line 8.

DISTRIBUTION

out of NH

LINE 10

Enter the total sales

to another state and complete Schedule 10. (This schedule shall be submitted in duplicate for each state).

LINE 11

Enter the total sales to NH licensed distributors and complete Schedule 11.

LINE 12

Enter wholesale bulk sales “…to the United States, it’s agencies or instrumentalities; and diplomatic or consular personnel certified by the

United States Department of State” and complete Schedule 12.

LINE 13

Enter wholesale bulk sales “… to the State of New Hampshire or its agencies” and “…to any city, town, county, school district, or village

district” and complete Schedule 13.

LINE 14

Enter gain or loss (only

from NH

wholesale bulk storage). Indicate gain as “G” and deduct.

LINE 15

Enter total non-taxable sales (add lines 10 through 14).

in NH

LINE 16

Enter total taxable sales

and complete Schedule 16 (With exception of fuel used in your own equipment).

LINE 17

Enter fuel used in your own equipment for personal use

from NH

wholesale bulk storage and complete Schedule 17.

LINE 18

Enter total of lines 16 and 17.

LINE 19

Enter total of lines 15 and 18 (this must equal the total shown on line 9).

TAX COMPUTATION

LINE 20

Enter total shown on line 18.

LINE 21

Enter total “retail” dealer sales to United States Government and it’s agencies as defined on line 21 and complete Schedule 21.

LINE 22

Enter total “retail” dealer sales to the State of NH and it’s agencies as defined on line 22 and complete Schedule 22.

LINE 23

Enter adjustments that may be an addition or a <deduction> to a prior month/year and give written detail. This schedule shall not be used

to show the results of a NH audit. (Without detailed explanations, your adjustment(s) may be disallowed.)

LINE 24

Results of lines 21 through 23.

LINE 25

Enter net taxable gallons (line 20 +/- line 24)

LINE 26

This is the current tax rate per gallon.

LINE 27

Multiply the gallons shown on line 25 by the tax rate on line 26.

RSA 260:38, I Provides that “ … on or before the twentieth day of each calendar month render a return to the department on forms prescribed and

furnished by the commissioner. The return shall show the total number of gallons sold and used in the state during the previous calendar month…”

RSA 260:40, I Provides that “ When any distributor shall fail to file a monthly report with the department at the time fixed in this subdivision, refuse to

submit the data required by RSA 260:38, or fail to pay the amount of road tolls due when they shall be payable, a penalty of 10 percent shall be added to

the amount of the road tolls due… Such penalty shall immediately accrue, and thereafter the overdue road tolls and the penalty shall bear interest as

specified in RSA 260:40-a.”

MFD 1-S/AF (Revised 07/05)