Form Rt115r - Schedule Of Sales To New Hampshire Retail Dealers - Departament Of Safety Road Toll Bureau, State Of New Hampshire

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STATE OF NEW HAMPSHIRE
For the Six Month Period of:
DEPARTMENT OF SAFETY
_________ Thru ___________
ROAD TOLL BUREAU
Schedule of Sales To New Hampshire Retail Dealers
Year ____________
Distributor Name:
Distributor FEIN:
Distributor Address:
Page _________ of _________
Retail Dealer Name:
Retail Station Address:
Retailer FEIN:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
CARRIER
CARRIER
MODE
ORIGIN
ACQUIRED FROM
DATE
DOCUMENT
FUEL
GROSS
NAME
FEIN
RECEIVED
NUMBER
TYPE
GALLONS
NAME
FEIN
NOTE: There must be one (1) schedule submitted for each product type
Total This Page
Grand Total
Form RT115R (07/05)

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