Form A-5 - Land Use Change Tax Page 2
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3NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
FORM
LAND USE CHANGE TAX
A-5
STEP 5 SIGNATURES OF A MAJORITY OF SELECTMEN/ASSESSORS
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
TYPE OR PRINT NAME (in black ink)
SIGNATURE (in black ink)
DATE
STEP 6 LAND USE CHANGE TAX NOTICE
(TO BE COMPLETED BY LOCAL ASSESSING OFFICIALS)
LAST NAME
FIRST NAME
ADDRESS
ADDRESS (continued)
TOWN/CITY
STATE
ZIP CODE+4
(a) Date of Release (MM/DD/YYYY)
(b) Date of Bill (MM/DD/YYYY)
$
(c) Full and True Value at Time of Change in Use
$
(d) Total Tax Due
STEP 7 CHECKS PAYABLE TO AND MAILED TO
(TO BE COMPLETED BY TAX COLLECTOR)
(a) Make Check Payable to:
NAME
(b) Mail To:
ADDRESS
TOWN/CITY
STATE
ZIP CODE+4
(c) Tax Collector’s Offi ce Location:
(d) Tax Collector’s Offi ce Hours:
(e) Include a separate check in the amount of $___________________________________________________
Payable to ________________________________________ for recording fee at County Register of Deeds.
(f) Payment of this tax is due no later than 30 days after mailing of this bill. Interest, at the rate of 18%
per annum, shall be due if this tax is not paid on or before ________________________________________
STEP 8 ACKNOWLEDGMENT OF PAYMENT
SIGNATURE (in black ink) OF TAX COLLECTOR
DATE PAID
Page 2 of 3
A-5
Rev 03/13
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