Form Ad-1 - Abandoned Deposit Amounts Return Form (Page 2 of 3) in pdf

Part 3. Unfunded Liability Balance

11. Previous month’s unfunded liability balance. Enter amount from line 5 of previous month’s Part 3

(must be approved by Commissioner per Regulation 830 CMR 94.323.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

12. Payment made for gradual funding for this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

13. Unfunded liability balance after payment. Subtract line 11, part 2 from line 6, part 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14. Credit for negative cash balance (from Part 2, line 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

15. Ending unfunded liability balance. Combine lines 3 and 4. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Part 4. Authorized Loan Balance

11. Balance of previously borrowed amounts. Enter amount from line 7 of previous month’s Part 4

(must be approved by Commissioner per Regulation 830 CMR 94.323.1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

12. Amount borrowed during the month (only if additional amount is approved by the Commissioner). . . . . . . . . . . . . . . . . . . 2

13. Loan balance. Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14. Authorized loan payment this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

15. Loan balance after repayment. Subtract line 4 from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

16. Credit for negative cash balance (from Part 2, line 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

17. Ending loan balance. Subtract line 6 from line 5. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Part 5. Interest in Fund

11. Unwithdrawn interest in fund at beginning of month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

12. Interest earned on fund this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

13. Subtotal. Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14. Interest withdrawn from fund this month. Not to exceed line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

15. Interest remaining in fund at the end of the month. Subtract line 4 from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Declaration

Under penalties of perjury, I declare that I have examined this return and to the best of my knowledge and belief, it is true, correct and complete.

Authorized signature

Title

Date

Form AD-1 shall be filed no later than ten (10) days after the last day of the month covered by this return. Any bottler or distributor who fails to file and

pay on time will be subject to interest charges on any unpaid amounts. If making a payment, make check or money order payable to the Commonwealth

of Massachusetts.

Mail to: Massachusetts Department of Revenue, PO Box 7008, Boston, MA 02204.

350 9/06 CRP0107

printed on recycled paper