Form Mfd For Schedules 10, 11, 16, 17 - Distribution - Nh Road Toll Bureau

Form Mfd For Schedules 10, 11, 16, 17 - Distribution - Nh Road Toll Bureau - 2005 Page 2

INSTRUCTIONS

“DISTRIBUTION”

MFD SCHEDULE 10-SALES & TRANSFERS OUT OF STATE

MFD SCHEDULE 11-SALES TO NH LICENSED DISTRIBUTORS

MFD SCHEDULE 16-TAXABLE SALES IN NH

MFD SCHEDULE 17-TAXABLE USE (PERSONAL)

This form is required by RSA 260:38, I and is designated as forms MFD 10, 11, 16 & 17. It is to be completed by an authorized representative and shall

include the following information:

1. Distributor Name

2. Federal Employer Identification Number (FEIN)

3. The schedule number the data represents

4. Period covered

5. Indicate if more than one page is used for a schedule

6. Each sale is to be listed individually, showing the date; transporter name and address; supplier; point of shipment & delivery; product type; sold

to (customer); and gallons. The term “various” for any of these items is NOT ACCEPTABLE.

7. When transporting by truck, show the transporters company name and address. If your company trucks are used, list your company name & address.

The terms “Our Truck” and “By Truck” are NOT ACCEPTABLE.

8. The total gallons for the page is to be shown. If more than one page is used for the individual schedule, the FINAL page of that schedule will contain

the amount to forward to the appropriate line on the MFD 1-S/AF report.

Tabulated computer listings containing the above data may be used, when approved, but must be attached to the appropriate schedule.

RSA 260:38 Determination and Payment of Road Toll.

I. For the purpose of determining the amount of road toll imposed and to be collected under this subdivision, each distributor shall 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 together with such other information as the commissioner may

require for the reasonable administration of this subdivision. Each distributor shall accompany the return with a check payable to the state treasurer for the

total amount of road toll shown by such return to be due.

FORMS MFD 10, 11, 16, 17 (Revised 07/05)