Form Mfd 21 - Tax Computation - 21-Retail Dealer Sales To Us Government

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STATE OF NEW HAMPSHIRE
SCHEDULE NUMBER: 21
ROAD TOLL BUREAU
“TAX COMPUTATION”
NOTICE
MONTH/YEAR____________
USE THIS FORM FOR SCHEDULE:
DISTRIBUTOR NAME: ____________________________
PAGE_______ OF _________
21-RETAIL DEALER SALES TO US GOVERNMENT
FEIN: _______________________________________________
RETAIL STATION
DELIVERY
PRODUCT
GOVERNMENT AGENCY
GALLONS
DATE
TYPE
NAME
LOCATION
TOTAL THIS PAGE-
NOTE: There must be one (1) schedule submitted for each product type or it may be disallowed
TOTAL TO LINE 21 ON THE MFD 1-S/AF REPORT
FORMS MFD 21 (Revised 11/06)

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