Form A-5 - Land Use Change Tax
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3FOR REGISTER OF DEEDS USE ONLY
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
FORM
A-5
LAND USE CHANGE TAX
STEP 1 PROPERTY OWNER(S) AND RESPONSIBILE PARTY (if applicable)
LAST NAME
FIRST NAME
INITIAL
LAST NAME
FIRST NAME
INITIAL
RESPONSIBLE PARTY, IF OTHER THAN PROPERTY OWNER [RSA 79-A:7, II(e)]
STREET ADDRESS
ADDRESS (continued)
TOWN/CITY
STATE
ZIP CODE+4
STEP 2 PROPERTY LOCATION
STREET
TOWN/CITY
COUNTY
NUMBER OF ACRES
CHECK ONE:
BOOK #
PAGE #
PARTIAL RELEASE
FULL RELEASE
MAP #
LOT #
MAP #
LOT #
MAP #
LOT #
STEP 3 LOCAL IDENTIFICATION OF LAND BEING DISQUALIFIED
BOOK #
PAGE #
(a) Owners Name of Record When Land Was First Classified
(b) Number of Acres Originally Classified
(c) Number of Acres Previously Disqualified
(d) Acres Disqualified per this Assessment
(e) Number of Acres Remaining in Current Use
[3(b) minus 3(c) and 3(d)]
STEP 4 ASSESSMENT OF LAND USE CHANGE TAX
(a) Narrative description of the disqualification:
(b) Actual Date of Change in Use (MM/DD/YYYY)
(c) Full and True Value at Time of Change in Use
$
(d) Land Use Change Tax [Step 4(c) x 10%]
$
Page 1 of 3
A-5
Rev 03/13
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