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NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
FORM
REAL ESTATE TRANSFER TAX DECLARATION OF
CD-57-HC
CONSIDERATION FOR REAL ESTATE HOLDING COMPANIES
281
Original Return
Amended Return
PRINT OR TYPE
FOR DRA USE ONLY
STEP 1
LAST NAME OR ENTITY
FIRST & INITIAL
TAXPAYER IDENTIFICATION NUMBER
PURCHASER
LAST NAME OR ENTITY
FIRST & INITIAL
TAXPAYER IDENTIFICATION NUMBER
GRANTEE
ASSIGNEE
NUMBER & STREET ADDRESS
TRANSFEREE
ADDRESS (CONTINUED)
CITY/TOWN, STATE & ZIP CODE
STEP 2
LAST NAME OR ENTITY
FIRST & INITIAL
TAXPAYER IDENTIFICATION NUMBER
SELLER
LAST NAME OR ENTITY
FIRST & INITIAL
TAXPAYER IDENTIFICATION NUMBER
GRANTOR
ASSIGNOR
NUMBER & STREET ADDRESS
TRANSFEROR
ADDRESS (CONTINUED)
CITY/TOWN, STATE & ZIP CODE
NAME
TAXPAYER IDENTIFICATION NUMBER
STEP 3
REAL
NUMBER & STREET ADDRESS
ESTATE
HOLDING
ADDRESS (CONTINUED)
COMPANY
CITY/TOWN, STATE & ZIP CODE
TYPE OF ENTITY
1
PROPRIETORSHIP
2
CORPORATION/COMBINED GROUP
3
PARTNERSHIP
4
FIDUCIARY
5
NON-PROFIT ORGANIZATION
STEP 4
MUNICIPALITY
PROPERTY
HELD BY
BOOK NO.
PAGE NO.
COUNTY
THE REAL
ESTATE
BRIEF DESCRIPTION: (SUCH AS MAP AND LOT NUMBERS; LOCATED AT 17 ELM STREET, AUBURN, OR 10 ACRES, FARM HOUSE AND BARN KNOWN AS SMITH FARM,
MILL ROAD, MILTON.)
HOLDING
COMPANY
IF MORE THAN ONE PROPERTY, ATTACH A SEPARATE SCHEDULE
STEP 5
DATE OF TRANSFER OF INTEREST IN REAL ESTATE HOLDING COMPANY: MONTH
DAY
YEAR
TRANSFER
DATE
Purchaser
Seller
STEP 6
FIGURE
1
FAIR MARKET VALUE OF ALL NEW HAMPSHIRE REAL ESTATE ..
$
THE
.
.
2
PERCENTAGE OF INTEREST TRANSFERRED
TAX
(Expressed as a decimal) ................................................................
$
3
CONSIDERATION (Line 1 x Line 2) ................................................
$
4
ROUND LINE 3 UP TO THE NEAREST $100 ................................
$
$
00
00
5
DIVIDE LINE 4 BY $100 ..................................................................
$
00
$
00
$
6
TAX RATE PER $100 AT TIME OF TRANSFER (see instructions) .
$
7
SUBTOTAL OF TAX (Line 5 multiplied by Line 6) ..........................
$
$
$
8(a) Interest ............................................................................................
$
8(b) Penalties .......................................................................................... $
$
9
BALANCE DUE: Make check payable to State of New Hampshire. ..
$
Enclose your payment with this return
STEP 7
Under penalties of perjury, I declare that I have examined this document and to the best of my belief it is true, correct and complete.
SIGNATURES
FOR DRA USE ONLY
PURCHASER’S SIGNATURE (IN INK)
DATE
SELLER’S SIGNATURE (IN INK)
DATE
PURCHASER’S SIGNATURE (IN INK)
DATE
SELLER’S SIGNATURE (IN INK)
DATE
PURCHASER’S SIGNATURE (IN INK)
DATE
SELLER’S SIGNATURE (IN INK)
DATE
WITNESS SIGNATURE (IN INK)
DATE
WITNESS SIGNATURE (IN INK)
DATE
NH DEPT OF REVENUE ADMINISTRATION
CD-57-HC
MAIL
109 PLEASANT ST, PO BOX 2035
Rev 6/2010
TO:
CONCORD NH 03302-2035