Form Dp-65s - Credit Claim For Recording Surcharge Stamps Or Indicia
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FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
DP-65S
CREDIT CLAIM FOR RECORDING SURCHARGE STAMPS OR INDICIA
Rev 3004.03
NAME:
REGISTER OF DEEDS
COUNTY:
AMOUNT OF CLAIM: $
ORIGINAL FILING PERIOD
Documentation on Errors, Voided Stamps, or Non-suffi cient funds (NSF).
1
DATE OF ISSUE:
2
NUMBER AND DENOMINATION OF SURCHARGE STAMPS ISSUED:
3
TYPE OF DOCUMENT SUBJECT TO RECORDING SURCHARGE
4
NAME, ADDRESS, AND TAX IDENTIFICATION NUMBER OF GRANTOR:
5
NAME ADDRESS, AND TAX IDENTIFICATION NUMBER OF GRANTEE:
6
BOOK AND PAGE NUMBER WHERE DOCUMENT IS RECORDED:
7
CIRCUMSTANCES UNDER WHICH ERRONEOUS ISSUE WAS MADE:
8
ENCLOSE :
a.
A PHOTO COPY OF THE DOCUMENT PAGE UPON WHICH THE ERRONEOUS STAMP/INDICIA WAS AFFIXED.
b.
COPY OF NSF ADVICE FROM BANK INCLUDING RELATED BANK FEES
c.
ORIGINAL CHECK RETURNED BY BANK FOR NSF
d.
ALLOCATION OF PAYMENT IF CHECK INCLUDED FEES OTHER THAN L-CHIP SURCHARGE
9
SIGNATURE OF REGISTER OF DEEDS OR AUTHORIZED AGENT
DATE
WHERE TO FILE: This form should be attached to the DP-4 for the period in which the credit is being claimed.
WHEN TO FILE:
Pursuant to Rev 3004.03, Form DP-65S Credit Claim for Recording Surcharge Stamps or Indicia erroneously issued and placed
on a recorded document shall be fi led with the Department for erroneously issued tax stamps, indicia, or non-suffi cient funds.
FOR DRA USE ONLY
DP-65S
Rev. 7/2008
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