New Hampshire  
                              Department of        $%    )$ 1                                 *CD57HP2311862*
                   Revenue Administration                                                                      CD57HP2311862

3&"- &45"5& 53"/4'&3 5"9 %&$-"3"5*0/ 0' $0/4*%&3"5*0/ '03 3&"- &45"5& )0-%*/( $0.1"/*&4  163$)"4&3 

45&1     163$)"4&3            Grantee / Assignee / Transferee             VTF NBJMJOH BEESFTT 
                                                                                                                                  Original Return
Entity Type  -(Check One):     Individual    Joint  Partnership               Corporation                      Trust    LLC       Amended Return

Last Name / Entity                                                       First Name                                  FEIN / SSN

Last Name / Entity                                                       First Name                                  FEIN / SSN

Street No.                  Street Name                                       Apt / Unit                             Phone Number 

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

45&1     4&--&3               Grantor / Assignor / Transferor             VTF NBJMJOH BEESFTT 
Last Name / Entity                                                       First Name

Last Name / Entity                                                       First Name

Street No.                  Street Name                                       Apt / Unit                             Phone Number 

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

45&1     3&"- &45"5& )0-%*/( $0.1"/:
Entity Type - (Check One):    Proprietorship Corporation / Combined Group                     Partnership      Fiduciary
Entity                                                                   FEIN 

Street No.                  Street Name                                       Apt / Unit                             Phone Number 

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

     CD-57-HC-P 
     7FSTJPO         0 /202                                                                                                       Page 1 of  

                 New Hampshire  
                        Department of                       $%    )$ 1                   *CD57HP2321862*
                Revenue Administration                                                                     CD57HP2321862
3&"- &45"5& 53"/4'&3 5"9 %&$-"3"5*0/ 0' $0/4*%&3"5*0/ '03 3&"- &45"5& )0-%*/( $0.1"/*&4  163$)"4&3 
45&1     3&"- &45"5&  `
Municipality                                   County
 
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        Residential    Commercial               Mixed Res / Comm Industrial               Other
(Check One):

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

45&1     53"/4'&3 %"5&                                                                                     Transfer Date

45&1     $"-$6-"5& 5)& 5"9 ".06/5
1) Fair market value of all NH real estate

2) Percentage of interest transferred (decimal)

3) Consideration (Line 1 multiplied by Line 2)

4) Divide Line 3 by $100

5) Tax rate per $100 at time of transfer (See instructions)                                                             0.75

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

7(a)  Interest

7(b)  Penalties
8) Total of Lines 6, 7(a),  and 7(b). Make check payable to 4UBUF PG /).
 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-P                                                                                                             Page 2 of  
 7FSTJPO            

                New Hampshire  
                        Department of                   $%    )$ 1      *CD57HP2331862*
                Revenue Administration                                                                                      CD57HP2331862

3&"- &45"5& 53"/4'&3 5"9 %&$-"3"5*0/ 0' $0/4*%&3"5*0/ '03 3&"- &45"5& )0-%*/( $0.1"/*&4  163$)"4&3 

45&1     13&1"3&3
Entity

Last Name                                                     First Name

Street No.              Street Name                           Apt / Unit                                                    Phone Number 

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

45&1     4*(/"563&4
1PXFS PG "UUPSOFZ  10" : By checking this box and signing below, you authorize the preparer listed on this return to act on your behalf for this return 
only.

5"91":&3h4 4*(/"563&   */'03."5*0/ (Purchaser'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. 
Purchaser 1 Signature                                                                                MMDDYYYY

Purchaser 1 Printed Name

Purchaser 2 Signature                                                                                MMDDYYYY

Purchaser 2 Printed Name

13&1"3&3h4 4*(/"563&   */'03."5*0/ (If prepared by someone other than the Purchaser) 
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-P                                                                                                                          Page 3 of  
     7FSTJPO            

                 New Hampshire  
                        Department of        $%    )$ 1                                       (FOFSBM 2VFTUJPOT
             Revenue Administration

8)"5 *4 3&"- &45"5& 53"/4'&3 5"9  
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. Tax rate from 7/1/99-Present is $0.75 per $100. 

8)"5 *4 " 3&"- &45"5& )0-%*/( $0.1"/:  
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. 

8)"5 *4 '"*3 ."3,&5 7"-6&  
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. 

8)&/ 50 '*-& 
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. 

8)0 .645 '*-& 
The purchaser, grantee, assignee, or transferee must sign and file the Declaration CD-57-HC-P 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.  

8)0 .645 1": 
The tax is assessed on both the purchaser and the seller, with a minimum charge of $20 each.  

8)&3& 50 '*-& 
File online at Granite Tax Connect HUD SFWFOVF OI HPW 5"1 @  or by mail to NH Department of Revenue Administration, Taxpayer Services 
Division, PO Box 637, Concord, NH 03302-0637 

1&/"-5*&4 
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. 

*O BEEJUJPO  UIFSF JT B QFOBMUZ FRVBM UP      PG UIF BEEJUJPOBM UBY EVF JG FJUIFS UIF CVZFS PS TFMMFS NBLFT B GBMTF TUBUFNFOU PO FJUIFS UIF 
USBOTGFS UBY GPSN PS EFFE UIBU OP UBY JT EVF  PS QBZT UBY PO MFTT UIBO UIF BDUVBM QSJDF PS DPOTJEFSBUJPO GPS UIF USBOTGFS  5IF      GBMTF 
TUBUFNFOU QFOBMUZ JT JO MJFV PG UIF     MBUF QBZNFOU QFOBMUZ  

/&&% '03.4  
To obtain additional forms please call (603) 230-5001. Copies of Form CD-57-HC-P may also be obtained from our web site at  
www.revenue.nh.gov. 

/&&% )&-1  
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-P *OTUSVDUJPOT                                                                                                     Page   of  
7FSTJPO            

                 New Hampshire  
                        Department of                    $%    )$ 1                  -JOF #Z -JOF *OTUSVDUJPOT
              Revenue Administration

45&1      1VSDIBTFS T  
Enter the full name and address of the purchaser(s), grantee(s), assignee(s) or transferee(s) and the taxpayer identification number(s).  Email 
address is an optional field.  Please attach a supplemental schedule for 2 or more purchasers. 

45&1      4FMMFS T  
Enter the full name and address of the seller(s), grantor(s), assignor(s) or transferor(s). Email address is an optional field.  Please attach a 
supplemental schedule for 2 or more sellers. 

45&1      3FBM &TUBUF )PMEJOH $PNQBOZ 
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 

45&1      3FBM &TUBUF 
1SPQFSUZ  -PDBUJPO  BOE  %FTDSJQUJPO: 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. 
1SPQFSUZ 6TF: Select the primary use of the parcel, only one option may be selected. 
1SPQFSUZ 5ZQF: Select the property type of the parcel, select all that apply. 
'FBUVSFT: 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. 

45&1      5SBOTGFS %BUF 
Enter the date of transfer of interest in the Real Estate Holding Company. 

45&1      $BMDVMBUF UIF 5BY "NPVOU 
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 purchaser by multiplying Line 4 by Line 5, rounded to the nearest                         INTEREST 
whole dollar.                                                                                                   1&3*0%       RATE
Line 7a: Interest is calculated on the balance of tax due from the original due date to the date paid. 1/1/20   - 12/31/202   %
See interest rate chart to the right                                                                   1/1/20   - 12/31/202   %
Line 7b:  Penalties.  See page  .                                                                      1/1/20   - 12/31/202   %
-JOF    &OUFS UIF UPUBM PG -JOFT      B  BOE   C                                                       1/1/201  - 12/31/20    %
                                                                                                       1/1/2017 - 12/31/2018 6%
45&1      1SFQBSFS                                                                                     1/1/2013 - 12/31/2016 5%
If this form was filled out by someone other than the purchaser, 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
45&1      4JHOBUVSFT  1BQFS 'PSN  
1PXFS PG "UUPSOFZ  10" : 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.  
1VSDIBTFShT 4JHOBUVSF BOE *OGPSNBUJPO:  The Form must be signed in ink and dated by the Purchaser(s). 
1SFQBSFShT 4JHOBUVSF BOE *OGPSNBUJPO: If the Form was prepared by someone other than the Purchaser, 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-P *OTUSVDUJPOT                                                                                                      Page   PG  
7FSTJPO