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                     New Hampshire  
                           Department of              CD-57-HC-S                      *CD57HS2311862*
                  Revenue Administration                                                                 CD57HS2311862
REAL ESTATE TRANSFER TAX DECLARATION OF CONSIDERATION FOR REAL ESTATE HOLDING COMPANIES (SELLER)

STEP 1 - SELLER            Grantor / Assignor / Transferor  (use mailing address)
                                                                                                                              Original Return
Entity Type  -(Check One):        Individual    Joint      Partnership          Corporation           Trust       LLC         Amended Return

Last Name / Entity                                                         First Name                          FEIN / SSN
WENTWORTH ENTERPRISES                                                                                             3   6 6   6 6 5 5      5   5
Last Name / Entity                                                         First Name                          FEIN / SSN

Street No.                 Street Name                                          Apt / Unit                     Phone Number 
9                          WOODS END ROAD
City                                                  State Zip Code + 4 (or Canadian Postal Code)
HANOVER                                               NH                   0 3 7 5 0
Email (optional)

STEP 2 - PURCHASER               Grantee / Assignee / Transferee           (use mailing address)
Last Name / Entity                                                         First Name
CHAMBERS                                                                   JENNIFER
Last Name / Entity                                                         First Name

Street No.                 Street Name                                          Apt / Unit                     Phone Number 
15                         RANGE RD
City                                                  State Zip Code + 4 (or Canadian Postal Code)
CONCORD                                               NH                   0 3 3 0 1
  Email (optional)

STEP 3 - REAL ESTATE HOLDING COMPANY
Entity Type - (Check One):       Proprietorship Corporation / Combined Group          Partnership        Fiduciary
Entity                                                                     FEIN 
WATERFORD INVESTMENT COMPANY                                               0    1 2   3         4 5 6 7 8
Street No.                 Street Name                                          Apt / Unit                     Phone Number 
1025                       BOYLSTON ST
City                                                  State Zip Code + 4 (or Canadian Postal Code)
BOSTON                                                MA
Email (optional)

     CD-57-HC-S 
     Version 1   8 0 /2023                                                                                                    Page 1 of 5

                 New Hampshire  
                      Department of                          CD-57-HC-S                   *CD57HS2321862*
                Revenue Administration                                                                        CD57HS2321862
REAL ESTATE TRANSFER TAX DECLARATION OF CONSIDERATION FOR REAL ESTATE HOLDING COMPANIES (SELLER)
STEP 4 - REAL ESTATE  
Municipality                                    County
BEAN'S GRANT                                    COOS
Street No.            Street Name                                                         Apt / Unit

Tax Map                                         Block                                               Lot

Acreage
                                                Number of Parcels Purchased
Multi Town Sale?                 If Yes, list municipalities:
Yes              No

Property Use                        Commercial               Mixed Res / Comm Industrial               Other
(Check One):          Residential

Property Type         Land Only     Building Only            Land & Building  Condo                    Condex        Land & Manufactured Housing
  (Check All  
   That Apply):       Manufactured Housing                   Multi-unit       Timber Rights            Mineral Rights

Features                                                     If multi-unit building, how many units?
(Check One):          Waterfront    Water Access

STEP 5 - TRANSFER DATE                                                                                        Transfer Date 1 0 1 5 2 0         2 3

STEP 6 - CALCULATE THE TAX AMOUNT
1) Fair market value of all NH real estate                                                                           2      5 9 0 0 0 .         0 0

2) Percentage of interest transferred (decimal)                                                                             0 . 5 0 0 0 0 0

3) Consideration (Line 1 multiplied by Line 2)                                                                       1 2      9 5 0 0 .         0 0

4) Divide Line 3 by $100                                                                                                      1 2 9 5 .      0    0

5) Tax rate per $100 at time of transfer (See instructions)                                                                         0 .         7 5

6) Subtotal of Tax (Minimum of $20 for all considerations $4,000 or less, per RSA 78-B:1)                                             9         7 1

7(a)  Interest

7(b)  Penalties

8) Total of Lines 6, 7(a),  and 7(b). Make check payable to State of NH.                                                              9         7 1
Enclose your payment with this return
Are you claiming tax                       If Yes, please explain:
exemption under          Yes      No
RSA 78-B:2?

CD-57-HC-S 
Version 1   8 0 /2023                                                                                                             Page 2 of 5

                   New Hampshire  
                           Department of                CD-57-HC-S      *CD57HS2331862*
                  Revenue Administration                                                                                   CD57HS2331862
REAL ESTATE TRANSFER TAX DECLARATION OF CONSIDERATION FOR REAL ESTATE HOLDING COMPANIES (SELLER)

STEP  7- PREPARER
Entity

Last Name                                                     First Name

Street No.                 Street Name                        Apt / Unit                                                   Phone Number 

City                                                    State Zip Code + 4 (or Canadian Postal Code)
                                                         
Email (optional)

STEP  8- SIGNATURES
     Power of Attorney (POA): By checking this box and signing below, you authorize the preparer listed on this return to act on your behalf for this return 
     only.

TAXPAYER'S SIGNATURE & INFORMATION (Seller's Signature is Required) 
Under penalties of perjury, I declare that I have examined this return and to the best of my belief it is true, correct and complete.  I also agree and affirm that the full 
price or consideration paid for the interest transferred through this transaction is as reported in Step 6(3) of this form.
Seller 1 Signature                                                                                   MMDDYYYY

Seller 1 Printed Name

Seller 2 Signature                                                                                   MMDDYYYY

Seller 2 Printed Name

PREPARER'S SIGNATURE & INFORMATION (If prepared by someone other than the Seller) 
Under penalties of perjury, I declare that I have examined this return and to the best of my belief it is true, correct and complete. (If prepared by a person other 
than the taxpayer, this declaration is based on all information of which the preparer has knowledge.)
Preparer's Signature (if other than taxpayer)                                                        MMDDYYYY

Preparer's Printed Name (required if POA box is checked)

     CD-57-HC-S 
     Version 1   8 0 /2023                                                                                                              Page 3 of 5

                New Hampshire  
                      Department of   CD-57-HC-S                                              General Questions
                Revenue Administration

WHAT IS REAL ESTATE TRANSFER TAX? 
It is a tax on the transfer, sale or granting of real property or an interest in real property. Where the price of consideration is $4,000 or less there is 
a minimum tax of $20 to both, the purchaser and the seller. The tax rate from 7/1/99 - Present is $0.75 per $100. 

WHAT IS A REAL ESTATE HOLDING COMPANY? 
A "Real Estate Holding Company" means an organization which is engaged principally in owning, holding, selling, or leasing real estate and 
which owns real estate or an interest in real estate within the state. 

WHAT IS FAIR MARKET VALUE? 
Rev 801.04 "Fair market value" means the price property would command if sold by a seller who is willing, but not compelled, to sell and 
purchased by a purchaser who is willing, but not compelled, to purchase. 

WHEN TO FILE 
A Declaration of Consideration for Real Estate Holding Companies must be filed with the NH Department of Revenue Administration (NH DRA) 
within 30 days of the transfer. 

WHO MUST FILE 
The seller, grantor, assignor, or transferor must sign and file the Declaration CD-57-HC-S with payment. A Declaration must be  filed for all 
transfers of interests in real estate holding companies, as defined by RSA 78-B:1-a, VI, holding real estate, or interest in real estate, the transfer of 
which would be taxable under the provisions of RSA 78-B if transferred directly.  

WHO MUST PAY 
The tax is assessed on both the purchaser and the seller, with a minimum charge of $20 each.  

WHERE TO FILE 
File online at Granite Tax Connect www.revenue.nh.gov/gtc or mail to NH Department of Revenue Administration, Taxpayer Services Division,  
PO Box 637, Concord, NH 03302-0637. 

PENALTIES 
FAILURE TO FILE: If a return is not filed on a timely basis, a failure to file penalty equal to 5% of the outstanding balance, with a minimum of $10 
per month, is charged for each of the first five months or parts thereof after the return is due.  The total amount of this penalty shall not exceed 
25% of the balance of tax due or $50, whichever is greater. 

FAILURE TO PAY: A penalty equal to 10% of any nonpayment or underpayment of taxes shall be imposed if the taxpayer fails to pay when due.  If 
the failure to pay is due to fraud, the penalty shall be 50% of the amount of nonpayment or underpayment. 

In addition, there is a penalty equal to 100% of the additional tax due if either the buyer or seller makes a false statement on either the
transfer tax form or deed that no tax is due, or pays tax on less than the actual price or consideration for the transfer. The 100% false
statement penalty is in lieu of the 10% late payment penalty. 

NEED FORMS? 
To obtain additional forms please call (603) 230-5001. Copies of Form CD-57-HC-S may also be obtained from our website at  
www.revenue.nh.gov. 

NEED HELP? 
Questions not covered here may be answered in our Frequently Asked Questions (FAQ) available on our website at www.revenue.nh.gov/ or by 
calling Taxpayer Services at (603) 230-5920, Monday through Friday, 8:00 am to 4:30 pm. All written correspondence to the Department 
should include the taxpayer name, taxpayer identification number, the name of a contact person and a daytime telephone number. Individuals 
who need auxiliary aids for effective communications in programs and services of the New Hampshire Department of Revenue Administration 
are invited to make their needs and preferences known. Individuals with hearing or speech impairments may call TDD Access: Relay NH 
1-800-735- 2964. 

CD-57-HC-S 
 Version 1   80 /2023                                                                                                      Page  4of 5

                 New Hampshire  
                      Department of                      CD-57-HC-S                      Line-By-Line Instructions
                Revenue Administration

STEP 1  - Seller(s) 
Enter the full name and address of the seller(s), grantor(s), assignor(s) or transferor(s) and the taxpayer identification number(s).  Email address 
is an optional field.  Please attach a supplemental schedule for 2 or more sellers. 

STEP 2  - Purchaser(s) 
Enter the full name and address of the purchaser(s), grantee(s), assignee(s) or transferee(s).  Email address is an optional field.  Please attach a 
supplemental schedule for 2 or more purchasers. 

STEP 3  - Real Estate Holding Company 
Enter the name, taxpayer identification number and address of the Real Estate Holding Company and check the appropriate box for entity type.
Email address is an optional field 

STEP 4  - Real Estate 
Property Location and Description: Enter the municipality, county, street number, street name, and apartment/unit number where the 
property is located.  Provide the tax map, block and lot (parcel identification number) used by the municipality to identify the parcel as well as 
the area in acres and the number of parcels purchased.  If the sale is a multi-town sale please enter all of the municipalities where parcels are 
located. 
Property Use: Select the primary use of the parcel, only one option may be selected. 
Property Type: Select the property type of the parcel, select all that apply. 
Features: Identify if the parcel is waterfront or has water access, if applicable.  Only one option may be selected.  For multi-unit buildings 
please indicate the number of units. 

Attach a supplemental schedule for additional properties. 

STEP 5  - Transfer Date 
Enter the date of transfer of interest in the Real Estate Holding Company. 

STEP 6  - Calculate the Tax Amount 
Line 1: Enter the fair market value of all New Hampshire real estate. 
Line 2: Enter the percentage of interest being transferred expressed as a decimal to six places. 
Line 3: Enter the result of Line 1 multiplied by Line 2. 
Line 4: Divide the amount on Line 3 by $100. 
Line 5: Enter the tax rate in effect as of the date of transfer.  Tax rate from 7/1/99 - Present is $0.75 per $100.  Please contact the NH DRA for rates 
prior to 7/1/99. 
Line 6: Enter the subtotal for the seller by multiplying Line 4 by Line 5, rounded to the nearest whole                        INTEREST 
dollar.                                                                                                           PERIOD       RATE
Line 7a: Interest is calculated on the balance of tax due from the original due date to the date paid.   1/1/2024 - 12/31/2024 9%
See interest rate chart to the right                                                                     1/1/2023 - 12/31/2023 7%
Line 7b:  Penalties.  See page 4.                                                                        1/1/2021 - 12/31/2022 5%
Line 8: Enter the total of Lines 6, 7(a) and 7(b).                                                       1/1/2019 - 12/31/2020 7%
                                                                                                         1/1/2017 - 12/31/2018 6%
STEP   7 - Preparer                                                                                      1/1/2013 - 12/31/2016 5%
If this form was filled out by someone other than the seller, please enter the full name, entity,        1/1/2012 - 12/31/2012 6%
address, phone number and email address (optional) of the preparer.                                      Contact NH DRA for rates prior to 1/1/2012

STEP   8- Signatures (Paper Form) 
Power of Attorney (POA): By checking the POA box, and signing below, the taxpayer authorizes the preparer listed in Step 8 to act on your 
behalf for this return only.  
Seller's Signature and Information:  The Form must be signed in ink and dated by the Seller(s). 
Preparer's Signature and Information: If the Form was prepared by someone other than the Seller, the Form must be dated and signed in ink 
by the preparer.  The preparer's printed name is also required if the POA box is checked.

CD-57-HC-S 
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