Form Cd-57hc - Real Estate Transfer Tax Declaration Of Consideration For Real Estate Holding Companies

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FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
CD-57HC
REAL ESTATE TRANSFER TAX DECLARATION OF
071
CONSIDERATION FOR REAL ESTATE HOLDING COMPANIES
FOR DRA USE ONLY
RSA 78-B:10
See reverse for instructions
PLEASE PRINT OR TYPE INFORMATION BELOW
PURCHASER,
GRANTEE, ASSIGNEE, TRANSFEREE:
1
FEIN OR SSN
IDENTITY:
NAME (S) (LAST, FIRST, M-INTL.) OR ENTITY NAME (S)
NUMBER AND STREET
CITY OR TOWN
STATE AND ZIP CODE
SELLER,
GRANTOR, ASSIGNOR, TRANSFEROR:
2
IDENTITY:
FEIN OR SSN
NAME (S) (LAST, FIRST, M-INTL.) OR ENTITY NAME (S)
NUMBER AND STREET
CITY OR TOWN
STATE AND ZIP CODE
3
REAL ESTATE HOLDING COMPANY:
NAME:
FEDERAL EMPLOYER IDENTIFICATION NUMBER:
TYPE OF ENTITY:
NUMBER AND STREET
CITY OR TOWN
STATE AND ZIP CODE
4
PROPERTY HELD BY THE REAL ESTATE HOLDING COMPANY (If more than one property, attach a separate schedule as needed):
CITY/TOWN
COUNTY
BOOK NO.
PAGE NO.
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.)
5
PERCENTAGE OF INTEREST IN REAL ESTATE HOLDING COMPANY BEING TRANSFERED:
%
DATE OF TRANSFER
MONTH
DAY
YEAR
STATEMENT OF FAIR MARKET VALUE AND CALCULATION OF TAX:
6
$
(a) FAIR MARKET VALUE OF ALL NEW HAMPSHIRE REAL ESTATE:.............................
(b) PERCENTAGE OF INTEREST TRANSFERRED:...........................................................
%
$
(c) CONSIDERATION [
.............................................................................
Line 6(a) x line 6 (b)]:
$
(d) ROUND LINE 6(c) UP TO THE NEAREST $100...........................................................
$
(e) DIVIDE LINE 6(d) BY $100.........................................................................................
$
(f) TAX RATE AT TIME OF TRANSFER per $100 or fractional part):..............................
$
(g) TAX DUE: Make check payable to STATE OF NH.....................................................
SIGNATURES:
7
BUYER (S)
SELLER (S)
FOR DRA USE ONLY
WITNESS:
WITNESS:
DATE:
DATE:
NH DEPT OF REVENUE ADMINISTRATION
Mail
DOCUMENT PROCESSING DIVISION
45 CHENELL DRIVE, PO BOX 2035
To:
CD-57HC
CONCORD NH 03302-2035
Rev 2/00

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