Form Mfd For Schedules 12, 13 - Distribution - Nh Road Toll Bureau - 2005

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STATE OF NEW HAMPSHIRE
NOTICE
SCHEDULE NUMBER:_______
ROAD TOLL BUREAU
USE THIS FORM FOR SCHEDULES:
“DISTRIBUTION”
MONTH/YEAR____________
12-BULK SALES TO U.S GOVERNMENT
DISTRIBUTOR NAME: ____________________________
13-BULK SALES TO LOCAL AND STATE GOVERNMENT
PAGE_______ OF _________
OR ITS AGENCIES
FEIN: _______________________________________________
TRANSPORTER
PURCHASED
POINT OF
DELIVERY
PRODUCT
GOVERNMENT AGENCY
FROM/OR
(CITY/STATE)
(CITY/STATE)
GALLONS
BE SPECIFIC)
DATE
NAME
ADDRESS
TYPE
(
SUPPLIER
SHIPMENT
DELIVERY
TOTAL THIS PAGE-
NOTE: There must be one (1) schedule submitted for each product type or it may be disallowed
TOTAL TO LINE 12 OR 13 ON THE MFD 1-S/AF REPORT
FORMS MFD 12, 13 (REV. 07/05)

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