Form Dp-4 - Monthly Report Of Taxes & Surcharge Fees Collected On Transfer Of Real Property
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FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
DP-4
MONTHLY REPORT OF TAXES & SURCHARGE FEES COLLECTED
ON TRANSFER OF REAL PROPERTY
071
FOR DRA USE ONLY
RSA 78-B
MONTH/YEAR
COUNTY
FEDERAL EMPLOYER IDENTIFICATION NUMBER
CONTACT NAME
TELEPHONE NUMBER
MAILING ADDRESS
CITY/TOWN
STATE
ZIP CODE
This report is to be fi led with the Document Processing Division on or before the 10th day of the month following the month of collection with copies of the
tax stamps issued. Completed Form DP-65 and/or DP-65S should also be attached if claimed on this DP-4.
RETT
L-CHIP
Column A
Column B
1(a) CONTROL NUMBER OF RETT STAMPS ISSUED
STEP 1
START #
END #
1(b) CONTROL NUMBER OF RETT STAMPS ISSUED
START #
END #
1(c) CONTROL NUMBER OF SURCHARGE FEE STAMPS ISSUED
START #
END #
1(d) ELECTRONICALLY AFFIXED STAMPS
START #
END #
1(e) ELECTRONICALLY AFFIXED STAMPS
START #
END #
1(f) TOTAL STAMPS ISSUED BY REGISTRY [Sum of lines 1(a) through 1(e)]
2
Enter the number of unused stamps in this registry as of the end of the reporting period.
3
TOTAL VALUE OF STAMPS ISSUED BY THE COUNTY
(RETT INCLUDES DP-3s)
4
VALUE OF TAXES & SURCHARGE FEES COLLECTED BY THE COUNTY
STEP 2
(Does not include DP-3s)
5
DEDUCTIONS
5(a) CREDITS CLAIM FOR ERRORS AND/OR VOIDED STAMPS
(Attached DP-65 per Rev 807.11 and/or stamps)
5(b) L-CHIP NON-SUFFICIENT FUNDS & VOIDED STAMPS
(Attach Form DP-65S per Rev 3004.03 recorded during the reporting month)
6
NET TRANSFER TAX & SURCHARGE FEES RECEIVED
Line 4 minus Line 5(a) and Line 5(b)
7
DEDUCT: 4% COMMISSION (Line 6 x .04)
8
ADD: 4% COMMISSION ON REFUNDS BY DRA
(Attach Form DP-3-Rs recorded during the reporting month)
9
SUBTOTAL OF TRANSFER TAX & SURCHARGE FEE DUE
Line 6 minus Line 7 plus Line 8
10
TOTAL DUE [Sum of Line 9 columns A & B]
11
DEDUCT: PAYMENT MADE ELECTRONICALLY
12
NET DUE (Line 10 minus Line 11)
STEP 3
I certify that, to the best of my knowledge and belief, this is a full, true and correct report.
TYPE/PRINT REGISTER OF DEEDS OR AUTHORIZED AGENT NAME
SIGNATURE OF REGISTER OF DEEDS OR AUTHORIZED AGENT (in black ink)
DATE
FOR DRA USE ONLY
DUE DATE:
10th day of the month following the month of collection.
NH DRA
DOCUMENT PROCESSING DIVISION
MAIL
PO BOX 637
TO:
DP-4
CONCORD, NH 03302-0637
Rev. 7/2008
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