Form Mfd For Schedules 10, 11, 16, 17 - Distribution - Nh Road Toll Bureau - 2005
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1
2NOTICE
STATE OF NEW HAMPSHIRE
SCHEDULE NUMBER:_______
USE THIS FORM FOR SCHEDULES:
ROAD TOLL BUREAU
“DISTRIBUTION”
MONTH/YEAR____________
10-SALES & TRANSFERS OUT OF STATE
11-SALES TO NH LICENSED DISTRIBUTORS
DISTRIBUTOR NAME: ____________________________
16-TAXABLE SALES IN NH
PAGE_______ OF _________
17-TAXABLE USE (PERSONAL)
FEIN:________________________________________________
TRANSPORTER
PURCHASED
POINT OF
DELIVERY
PRODUCT
SOLD TO
FROM/OR
(CITY/STATE)
(CITY/STATE)
GALLONS
DATE
NAME
ADDRESS
TYPE
(Name, City & State)
SUPPLIER
SHIPMENT
DELIVERY
-SCHEDULE 10 SHALL BE SUBMITTED IN DUPLICATE FOR EACH STATE-
TOTAL THIS PAGE-
NOTE: There must be one (1) schedule submitted for each product type or it may be disallowed
TOTAL TO LINE 10, 11, 16 OR 17 ON THE MFD 1-S/AF REPORT
FORMS MFD 10, 11, 16, 17 (Revised 07/05)
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