Form CD-57-HC-S Fillable Real Estate Transfer Declaration of Consideration for Holding Companies (Seller)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

COUNTY Enter the date of transfer of interest in the Real Estate Enter the municipality where the Enter the name taxpayer Prior to 1/1/2006 contact NH DRA $0 50 per $100 $0 525 per $100 $0 75 per $100 ( 2SSN) ( 2SSNB) (Add1) (Add1B) (Addr2a) (Addr2aB) (AddressAC) (AddressAC1) (AdressAB) (Amount1) (Amount2) (Amount3) (Amount4) (Amount5) (Amount6) (Amount7) (Amount7a) (Amount8) (Amount8a) (Amount8F) (Amount8G) (Amount8H) (Amount8I) (Amount8J) (Amount8K) (Amount8Ka) (Amount8L) (Amount9asda) (BookNo) (Cents1) (Cents2) (Cents7) (Cents7a) (Cents8a) (Cents8b) (Cents8H) (Cents8I) (Cents8J) (Cents8Ja) (Cents8K) (Cents8Ka) (Check Box11) Unchecked (Check Box12) Unchecked (Check Box13) Unchecked (Check Box13a) Unchecked (Check Box14) Unchecked (Check Box15) Unchecked (Check Box16) Unchecked (City1) (City1B) (County) (Date1) (Date2) (Date3) (Date4) (Day) (DescStep4) (DescStep4a) (Expressed as a decimal) (FirstName) (FirstName2) (FirstName2B) (FirstName2x) (LastName) (LastName2) (LastName2B) (LastNameB) (Line 1 multiplied by Line 2) (Month) (Municipality) (NameAB) (PageNo) (See tax rate chart) (SSN1) (SSN1aB) (Year) 03302 2035 1/1/2006 12/31/2006 1/1/2007 12/31/2007 1/1/2008 12/31/2008 1/1/2009 12/31/2009 1/1/2010 12/31/2012 109 PLEASANT ST PO BOX 2035 3 CONSIDERATION 4 by $100 4/1/90 6/30/93 7/1/93 6/30/99 7/1/99 Present 8(a) Interest 8(b) Penalties 9 Total of Lines 7 8(a) and 8(b) Make check payable to State of A "Real Estate Holding Company" means a business organization as A Declaration of Consideration for Real Estate Holding Companies must addition there is a penalty equal to 100% of the additional tax due ADDRESS (CONTINUED) ADDRESS (CONTINUED) Administration are invited to make their needs and preferences known am 4:30 PM All written correspondence to the Department should AMENDED RETURN and the seller in the columns provided annual gross receipts from the ownership or disposition of real estate; as of the date of transfer ASSIGNEE ASSIGNOR be filed with the NH Department of Revenue Administration (NH DRA) BOOK NO BRIEF DESCRIPTION: (SUCH AS MAP AND LOT NUMBERS; LOCATED AT 17 ELM STREET AUBURN OR 10 ACRES FARM HOUSE AND BARN KNOWN AS SMITH FARM by a purchaser who is willing but not compelled to purchase CALCULATE CD 57 HC S CD 57 HC S CD 57 HC S may also be obtained from our web site at charge of $20 each CITY/TOWN STATE & ZIP CODE CITY/TOWN STATE & ZIP CODE communication in programs and services of the Department of Revenue COMPANY Company and check the appropriate box for entity type concerning the Real Estate Transfer Tax Monday through Friday 8:00 CONCORD NH 03302 2035 CONSIDERATION FOR REAL ESTATE HOLDING COMPANIES Contact the Audit Division by calling (603) 230 5030 with questions CORPORATION/COMBINED GROUP DATE OF TRANSFER OF INTEREST IN REAL ESTATE HOLDING COMPANY: MONTH Date of transfer: DAY YEAR decimal to two places Declaration CD 57 HC P Declaration CD 57 HC S with payment A Declaration must be filed for all defined by RSA 78 B:1 a VI holding real estate the transfer of which defined in RSA 77 A:1 I which is engaged in the business of holding DIVIDE LINE 4 BY $100 Divide the amount on line Documents Processing Division PO Box 2035 Concord NH Enter the fair market value of all New Hampshire real estate Enter the percentage of interest being transferred expressed as a Enter the results of Line 1 multiplied by Line 2 Enter the subtotal for both the Enter the tax rate in effect Enter the total of Lines 7 8(a) and 8(b) for the seller rounded to the ESTATE exclusive of goodwill Fair market value and tax calculation for both the purchaser and FAIR MARKET VALUE OF ALL NEW HAMPSHIRE REAL ESTATE FIDUCIARY File the Declaration of Consideration and payment with: NH DRA FIRST & INITIAL FIRST & INITIAL FOR DRA USE ONLY for each of the first five months or parts thereof after the return is due GRANTEE grantee(s) assignee(s) or transferee(s) Please attach a supplemental GRANTOR grantor(s) assignor(s) or transferor(s) and the taxpayer identification Hearing or speech impaired individuals may call: TDD Access: Relay HELD BY HOLDING Holding Company identification number and address of the Real Estate Holding If a return is not filed on a timely basis a failure to file penalty equal to 5% if either the buyer or seller makes a false statement on either the IF MORE THAN ONE PROPERTY ATTACH A SEPARATE SCHEDULE if sold by a seller who is willing but not compelled to sell and purchased in real property Where the price of consideration is $4 000 or less there include the taxpayer name the name of a contact person and a daytime Instructions INTEREST Interest is calculated on the balance of tax due from the original due is a minimum tax of $20 to both the purchaser and the seller See the It is a tax on the transfer sale or granting of real property or an interest LAST NAME OR ENTITY LAST NAME OR ENTITY Line 1 Line 2 Line 3 Line 4 Line 5 Line 6 Line 7 Line 8(a) Line 9 LINE BY LINE INSTRUCTIONS MILL ROAD MILTON ) multiplying line 5 by line 6 MUNICIPALITY nearest dollar Mail payment with this form NEED FORMS? NEED HELP? NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION New Hampshire Enclose your payment with this return NH 1 800 735 2964 Individuals who need auxiliary aids for effective NH DRA NON PROFIT ORGANIZATION NUMBER & STREET ADDRESS NUMBER & STREET ADDRESS number(s) Please attach a supplemental schedule for 3 or more of the outstanding balance with a minimum of $10 per month is charged or holds real estate the fair market value of which comprises more ORIGINAL RETURN PAGE NO PARTNERSHIP PENALTIES Penalties (See general instructions above) PERCENTAGE OF INTEREST TRANSFERRED PERIOD PRINT OR TYPE Prior to 1990 contact the NH DRA PROPERTY property is located Enter the book number page number and county Property location and description: PROPRIETORSHIP Purchaser purchaser and the seller by Purchaser: Enter the full name and address of the purchaser(s) Real Estate Holding Company: REAL ESTATE TRANSFER TAX DECLARATION OF recorded Give a brief description of the property in the space provided Rev 08/2011 Rev 801 04 "Fair market value" means the price property would command ROUND LINE 3 UP TO THE NEAREST $100 Round the amount on Line 3 up to the nearest $100 RSA 78 B:10 schedule for 3 or more sellers Seller SELLER S SIGNATURE (IN INK) Seller: Enter the full name and address after sale of the seller(s) sellers SELLER'S SIGNATURE (IN INK) selling or leasing real estate which derives more than 50 percent of its signature(s) in ink must be witnessed and dated in spaces provided SIGNATURES Signatures in ink of the seller(s) is required The Signatures: statement penalty is in lieu of the 10% late payment penalty STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6 STEP 7 SUBTOTAL OF TAX (Line 5 multiplied by Line 6) TAX RATE CHART tax rate chart in Step 6 below for applicable tax rates TAX RATE PER $100 AT TIME OF TRANSFER (See instructions) TAXPAYER IDENTIFICATION NUMBER TAXPAYER IDENTIFICATION NUMBER TDD ACCESS telephone number than 50 percent of the total market value of the assets of the company the actual price or consideration for the transfer The 100% false The purchaser grantor assignor or transferor must sign and file the THE REAL the seller Enter the results of the calculations for both the purchaser The seller grantor assignor or transferor must sign and file the THE TAX The tax is assessed on both the purchaser and the seller with a minimum To obtain additional forms please call (603) 230 5001 Copies of Form to the date paid (See interest rate chart at right) to the Department TRANSFER transfer tax form or deed that no tax is due or pays tax on less than TRANSFEREE TRANSFEROR transfers of transferrable interests in real estate holding companies as TYPE OF ENTITY Under penalties of perjury I declare that I have examined this document and to the best of my belief it is true correct and complete WHAT IS A REAL ESTATE HOLDING COMPANY? WHAT IS FAIR MARKET VALUE? WHAT IS REAL ESTATE TRANSFER TAX? WHEN TO FILE where the property held by the Real Estate Holding Company is WHERE TO FILE WHO MUST FILE WHO MUST PAY within 30 days of the transfer WITNESS SIGNATURE (IN INK) would be taxable under the provisions of RSA 78 B if transferred directly www nh gov/revenue