Form A-5w - Current Use Land Use Change Tax Collector'S Warrant

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NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION

FORM

A-5W

CURRENT USE LAND USE CHANGE TAX COLLECTOR’S WARRANT

TAX COLLECTOR’S WARRANT FOR TOWN/CITY

TOWN/CITY OF

STREET ADDRESS

ADDRESS (continued)

TOWN/CITY

STATE

ZIP CODE+4

COLLECTION OF LAND USE CHANGE TAX

State of New Hampshire, County of

Collector of Taxes

for the Town/City of

in said County.

In the name of said State you are directed to collect the

LAND USE CHANGE TAX in the list herewith committed

to you, amounting in all of the sum of:

Interest at 18% will be assessed after 30 days.

Given under our hands at

This day of

OWNER NAME

OWNER ADDRESS

MAP

LOT

SIGNATURES OF A MAJORITY OF SELECTMEN/ASSESSORS