Form Ad-1 - Abandoned Deposit Amounts Return Form
ADVERTISEMENT
1
2
3Rev. 11/03
Form AD-1
Massachusetts
Abandoned Deposit
Department of
Amounts Return
Revenue
This form must be completed by all bottlers and distributors subject to the provisions of MGL Ch. 94, §323(c), (d) and (e).
Name of taxpayer
Tax period (month and year)
Federal Identification or Social Security number
Telephone number
Address
City/Town
State
Zip
Part 1. Reimbursement Calculation
11. Total number of nonreusable beverage containers for which refund values were received this month . . . . . . . . . . . . . . . . 1
12. Total number of nonreusable beverage containers for which refund values were paid this month. . . . . . . . . . . . . . . . . . . . 2
13. Beginning deposit transaction fund balance amount (see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
14. Reimbursement amount from previous month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
15. Total refund values received this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
16. Subtotal. Add lines 3 through 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
17. Abandoned deposit amounts from preceding month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
18. Total refund values paid this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
19. Subtotal. Add lines 7 and 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10. Ending deposit transaction fund balance amount. Subtract line 9 from line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11. Total refund values received during most recent three-month period (include this month) . . . . . . . . . . . . . . . . . . . . . . . . 11
12. Total abandoned deposit amounts. Subtract line 11 from line 10. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13. Penalty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14. Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15. Total payment due at time of filing. Add lines 12 through 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
If line 10 is positive (“0” or greater), do not complete this section.
16. Enter negative amount from line 10 as a positive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
17. Abandoned deposit amounts in preceding 24 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
18. Reimbursement amounts in preceding 24 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
19. Subtotal. Subtract line 18 from line 17. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20. Reimbursement amount. Enter the amount in line 16 or line 19, whichever is smaller . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Part 2. Reconciled Deposit Transaction Fund Cash Balance and Credits.
Attach most recent bank statement.
11. Beginning deposit transaction fund cash balance. Enter amount from line 12of previous
month’s Part 2. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
12. Interest income earned this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
13. Refund values received this month (from Part 1, line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
14. Payment made for gradual funding this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
15. Authorized loan payment this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
16. Subtotal. Add lines 1 through 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
17. Interest income withdrawn this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
18. Refund values paid this month (from Part 1, line 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
19. Authorized loan withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10. Abandoned deposit amount paid for the month (from Part 1, line 12) . . . . . . . . . . . . . . . . . . . . . 10
11. Subtotal. Add lines 7 through 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12. Ending deposit transaction fund cash balance. Subtract line 11 from line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
If “0” or greater, enter amount and stop here. Otherwise, enter negative amount and complete lines 13 & 14
13. Reimbursement amount (from Part 1, line 20). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14. Credit. Combine lines 12 and 13. If less than “0,” enter in Part 3, line 4 or Part 4, line 6. . . . . . . . . . . . . . . . . . . . . . . . . . 14
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