DO NOT STAPLE

                          New Hampshire  
                          Department of                         CD-57-S                  *0CD57S2411862*
                  Revenue Administration                                                                       0CD57S2411862
 REAL ESTATE TRANSFER TAX DECLARATION OF CONSIDERATION REAL ESTATE SELLER (GRANTOR)
STEP 1 - SELLER                    Grantor / Assignor / Transferor            (use new mailing address)
                                                                                                                             Original Return
Entity Type - (Check One):          Individual Joint            Partnership            Corporation   Trust      LLC
                                                                                                                             Amended Return
Seller 1 - Last Name / Entity                                                 First Name                        FEIN / SSN

Seller 2 - Last Name / Entity                                                 First Name                        FEIN / SSN

Street No.                Street Name                                                  Apt / Unit               Phone Number 

City                                                           State     Zip Code + 4 (or Canadian Postal Code)
                                                                
STEP 2 - PURCHASER               Grantee / Assignee / Transferee            
Last Name / Entity                                                            First Name

Last Name / Entity                                                            First Name

STEP 3 - REAL ESTATE
Municipality                                   County
 
Street No.                Street Name                                                  Apt / Unit

Multi Town Sale?                   If Yes, list municipalities:
     Yes          No

STEP 4 - DEED             Transfer Date                        Recording Date                        Book No.         Page No.

                          Warranty             Quitclaim        Mortgage      Sheriffs               Foreclosure
Deed Type                                                                                Tax

(Check one):              Commissioner's       Fiduciary        Probate       In Lieu of Foreclosure 5SBOTGFS PO %FBUI

     CD-57-S                                                                                                                  Page 1 of  
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                   New Hampshire  
                     Department of                           CD-57-S                              *0CD57S2421862*
                Revenue Administration                                                                            0CD57S2421862

REAL ESTATE TRANSFER TAX DECLARATION OF CONSIDERATION REAL ESTATE SELLER (GRANTOR)
STEP 5 - TAX AMOUNT

a) Full price or consideration for the real estate

b) Divide Line 5(a) by $100

c) Tax rate per $100 at time of transfer                                                                                       0.75

d) Subtotal of Seller's tax (Minimum of $20 for all considerations $4,000 or less, per RSA 78-B:1)

e) Total tax paid to County on behalf of Seller and Purchaser

Are you claiming tax                     DO NOT file form CD-57-S for transfers specifically exempted from taxation under RSA 78-B:2, EXCEPT transfers exempted 
exemption under      Yes   No            by RSA 78-B:2, IX. Form CD-57-S must be filed for non-contractual transfers exempted under RSA 78-B:2, IX.
RSA 78-B:2?

STEP 6 - 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 real estate transferred by this deed is as reported in Step 5(a) of this form.
Seller 1 Signature                                                                                MMDDYYYY

Seller 1 Printed Name

Seller 2 Signature                                                                                MMDDYYYY

Seller 2 Printed Name

CD-57-S                                                                                                                        Page 2 of  
7FSTJPO            

                        New Hampshire  
                        Department of                   CD-57-S                               *0CD57S2431862*
             Revenue Administration                                                                          0CD57S2431862

REAL ESTATE TRANSFER TAX DECLARATION OF CONSIDERATION REAL ESTATE SELLER (GRANTOR) 
                                                        SIGNATURE PAGE
STEP 7 - PREPARER'S SIGNATURE & INFORMATION (If prepared by someone other than the Seller)
     Power of Attorney (POA): By checking this box and signing Step 6, you authorize the preparer listed on this return to act on your behalf for this return 
     only, including entering the book and page numbers and filing this return electronically.

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)

Entity

Last Name                                                       First Name

Street No.              Street Name                             Apt / Unit                                   Phone Number 

City                                                    State Zip Code + 4 (or Canadian Postal Code)
                                                         
     CD-57-S                                                                                                              Page 3 of  
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