Fillable A-5 Form Land Use Change Tax (TOWN OF ANDOVER)

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A-5 Form Land Use Change Tax (TOWN OF ANDOVER)

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BROWSE TOWN OF ANDOVER (NH) FORMS

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Page 1 of 5
A-5
Version 1.3 02/2020
MUNICIPALITY LAND USE CHANGE TAX BILL
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
A-5
FORM
PLEASE TYPE OR PRINT
PLEASE TYPE OR PRINT
STEP 1- LAND USE CHANGE TAX TO BE BILLED TO:
STEP 2 - PARCEL IDENTIFICATION OF DISQUALIFIED CURRENT USE LAND
STEP 3 - DOCUMENTATION AND FEE FOR PROPERTY TO BE ENROLLED IN CURRENT USE (CU)
NOTE: A separate land use change tax (LUCT) must be submitted for each separate parcel of land.
(b) Total Number of Acres Originally Enrolled in Current Use
(e) Number of Acres Remaining in Current Use [3(b) minus 3(c) and 3(d)]
(d) Number of Acres Subject to the LUCT Per This Assessment
(c) Total Number of Acres Previously Released Since The Original Recording
DEED BOOK AND PAGE #
(a) Owners Name When Land Was First Recorded in Current Use:
(a) RIGHT OF WAY LAND USE CHANGE TAX - PROVIDE NAME OF LANDOWNER ON WHICH THE RIGHT OF WAY IS LOCATED
PROPERTY OWNER(S) OR
RIGHT OF WAY RESPONSIBLE PARTY LISTED BELOW:
PARTIAL RELEASE
FULL RELEASE
RIGHT OF WAY LAND USE CHANGE TAX
DEED BOOK AND PAGE # PARCEL TAX MAP AND LOT #
(d) CHECK ONE BELOW:
(c) TOTAL ACRES OF PARCEL
LAST NAME/CORPORATION/TRUST NAME FIRST NAME/CORPORATION/TRUST NAME
INITIAL
MUNICIPALITY STATE
ZIP CODE
MAILING ADDRESS
LAST NAME/CORPORATION/TRUST NAME FIRST NAME/CORPORATION/TRUST NAME
INITIAL
LAST NAME/CORPORATION/TRUST NAME FIRST NAME/CORPORATION/TRUST NAME
INITIAL
LAST NAME/CORPORATION/TRUST NAME FIRST NAME/CORPORATION/TRUST NAME INITIAL
MUNICIPALITY (b) ACCESSIBLE STREET LOCATION
COUNTY
Page 2 of 5
A-5
Version 1.3 02/2020
MUNICIPALITY LAND USE CHANGE TAX BILL
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
A-5
FORM
STEP 4 - ASSESSMENT OF LAND USE CHANGE TAX
(a) Narrative Description of the Disqualification:
(b) Actual Date of Change in Use (MM/DD/YYYY)
(c) Full and True Market Value at Time of Change in Use
(d) Land Use Change Tax [Step 4(c) multiplied by 10%]
$
$
(continued)
STEP 5 - SIGNATURES OF A MAJORITY OF THE MUNICIPAL ASSESSING OFFICIALS
TYPE OR PRINT NAME (in black or dark blue ink)
SIGNATURE (in black or dark blue ink)
DATE
TYPE OR PRINT NAME (in black or dark blue ink) SIGNATURE (in black or dark blue ink)
DATE
TYPE OR PRINT NAME (in black or dark blue ink) SIGNATURE (in black or dark blue ink)
DATE
TYPE OR PRINT NAME (in black or dark blue ink)
SIGNATURE (in black or dark blue ink)
DATE
SIGNATURE (in black or dark blue ink)
DATE
TYPE OR PRINT NAME (in black or dark blue ink)
STEP 6 - BILL LAND USE CHANGE TAX TO: (COMPLETED BY MUNICIPAL ASSESSING OFFICIALS)
LAST NAME/CORPORATION/TRUST NAME FIRST NAME/CORPORATION/TRUST NAME
INITIAL
MAILING ADDRESS
MUNICIPALITY STATE
ZIP CODE
(b) Actual Date of Change in Use (MM/DD/YYYY)
(c) Date of Land Use Change Tax Bill (MM/DD/YYYY)
(d) Full and True Market Value at Time of Change in Use
$
(e) Land Use Change Tax Due
$
Page 3 of 5
A-5
Version 1.3 02/2020
MUNICIPALITY LAND USE CHANGE TAX BILL
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
A-5
FORM
(continued)
STEP 7 - CHECKS PAYABLE AND MAILED TO: (COMPLETED BY MUNICIPAL TAX COLLECTOR)
(a) MAKE CHECKS PAYABLE TO:
(b) MAIL TO:
MAILING ADDRESS:
MUNICIPALITY STATE
ZIP CODE
(c) MUNICIPAL TAX COLLECTOR PHYSICAL OFFICE LOCATION:
(d) MUNICIPAL TAX COLLECTOR OFFICE HOURS:
(e) LAND USE CHANGE EXEMPT FROM RECORDING RSA 79-A:7, I (c):
Yes
No
(f) RECORDING FEE: INCLUDE A SEPARATE CHECK IN THE AMOUNT OF $
PAYABLE TO:
(g) PAYMENT OF THE LAND USE CHANGE TAX IS DUE NO LATER THAN 30 DAYS AFTER MAILING OF THIS BILL. INTEREST, AT THE RATE OF
18% PER ANNUM, SHALL BE DUE IF THE TAX IS NOT PAID ON OR BEFORE:
STEP 8 - ACKNOWLEDGEMENT OF PAYMENT (COMPLETED BY MUNICIPAL TAX C OLLECTOR)
TYPE OR PRINT NAME (in black or dark blue ink)
SIGNATURE OF MUNICIPAL TAX COLLECTOR (in black or dark blue ink)
DATE OF PAYMENT
A-5 INSTRUCTIONS
Version 1.3 02/2020
MUNICIPALITY LAND USE CHANGE TAX BILL
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
Page 4 of 5
A-5
FORM
INSTRUCTIONS
GENERAL INSTRUCTIONS
WHO MUST FILE
The Municipal Assessing Officials shall complete the Form A-5, Municipality Land Use Change Tax Bill, to assess the Land Use
Change Tax on land that has been classified as open space land and assessed at current use values on or after April 1, 1974 that has
undergone a change and as such, no longer qualifies for current use assessment.
WHEN TO FILE
Municipal Assessing Officials shall assess the Land Use Change Tax within 18 months of the date upon which they receive written
notice of the change of use from the landowner or his or her agent, or within 18 months of the date the Municipal Assessing
Officials actually discover the Land Use Change Tax is due and payable.
WHERE TO FILE
Upon approval and signature of the Form A-5 by the majority of the Municipal Assessing Officials, the original and two copies of
the Form A-5 along with the Form A-5W, Land Use Change Tax Warrant, shall be submitted to the Municipal Tax Collector for
collection of the Land Use Change Tax. A copy of the Form A-5 and Form A-5W shall be retained by the Municipal Assessing
Officials.
BILLING AND COLLECTION OF THE TAX
Upon receipt of the Land Use Change Tax Warrant, the Municipal Tax Collector shall mail one copy of the Form A-5 and this
instruction page to the property owner of right-of-way responsible party. Payment of the Land Use Change Tax shall be due no
later than 30 days after the mailing of the Form A-5 bill. If billed to the property owner, they must pay a recording fee. Interest of
18% will accrue on any unpaid tax after 30 days. Upon receipt of payment by the property owner, the Form A-5 is recorded at the
country registry of deeds. Upon receipt of payment by the right-of-way responsible party, the Form A-5 is not recorded at the
registry of deeds. Copies of the paid Form A-5 bills shall be given to the Municipal Assessing Officials for their records.
APPEAL OF LAND USE CHANGE TAX
Any person aggrieved by the assessment of a Land Use Change Tax may, within 2 months of the notice of tax date and not
afterwards, apply in writing to the Municipal Assessing Officials for an abatement of the Land Use Change Tax pursuant to RSA 79-
A:10. If the Municipal Assessing Officials neglect or refuse to abate the Land Use Change Tax, any person aggrieved may appeal
within 8 months of the notice of tax date and not afterwards, to either the Board of Tax and Land Appeals or Superior Court in
accordance with RSA 79-A:10 or RSA 79-A:11.
ADA
Individuals who need auxiliary aids for effective communication in programs and services of the department are invited to make
their needs and preferences known to the NH Department of Revenue Administration.
NEED HELP?
Contact your Municipality or Municipal and Property Division at (603) 230-5950.
A-5 INSTRUCTIONS
Version 1.3 02/2020
MUNICIPALITY LAND USE CHANGE TAX BILL
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
Page 5 of 5
A-5
FORM
INSTRUCTIONS
LINE-BY-LINE INSTRUCTIONS
The Municipal Assessing Officials shall complete Steps 1 through 6. Steps 7 and 8 shall be completed by the
Municipal Tax Collector.
STEP 1
Indicate whether the property owner or the right-of-way responsible party will be assessed the tax. Provide the names and address
of the party to whom the tax is being assessed.
STEP 2
(a) If assessed to the right-of-way responsible party, list the name of the parcel landowner on which the change occurred.
(b) Provide the parcel street location, municipality, and country on which the change in use occurred.
(c) Provide the total acres of the parcel, tax map and lot number, and most recent deed reference for the parcel.
(d) Indicate whether a portion of the parcel or the entire parcel is being released, or that it is a right-of-way change.
STEP 3
(a) Provide the name of the property owner(s) that originally enrolled the land into current use including the registry of deeds book
and page recording the reference.
(b) Enter the total acres originally enrolled in current use.
(c) Enter the total acres previously released since the original enrollment into current use.
(d) Enter the number of acres subject to the Land Use Change Tax for this assessment.
(e) Enter the number of acres remaining in current use, Step 3(b) minus Step 3(c) minus Step 3 (d).
STEP 4
(a) Provide the description of the land disqualification.
(b) Provide the actual date of the event that disqualified the land in the following format: MM/DD/YYYY.
(c) Provide the full and true market value of the land at the time of change in use.
(d) Calculate the Land Use Change Tax by multiplying the full and true market value of the land by 10% (.10).
STEP 5
Signature of a majority of the Municipal Assessing Officials and date of signature indicates approval.
STEP 6
(a) Provide the name and address of the party to whom the tax is to be billed.
(b) Provide the actual date of the event that disqualified the land in Step 4(b) in the following format: MM/DD/YYYY.
(c) Enter the date of the Land Use Change Tax Notice.
(d) Enter the full and true market value at the time of change in use as indicated in Step 4(c).
(e) Enter the Land Use Change Tax owed as calculated on page 2, Step 4(d).
STEP 7
(a) Enter the name of the municipality to which the checks are to be made payable. This should be the municipality in which the
parcel of land is located.
(b) Enter the name of the Municipal Tax Collector and the applicable mailing address to which payments should be remitted.
(c) Enter the Municipal Tax Collector's physical office location.
(d) Enter the Municipal Tax Collector's hours of operation.
(e) If the Land Use Change Tax is being billed to the right-of-way responsible party, it is exempt from recording and the box should
be checked "Yes". If the Land Use Change Tax is being billed to the property owner, it is not exempt and the box should be checked
"No".
(f) Enter the applicable county registry of deeds recording and filing fee for the recording of the lien release. Indicate to whom the
recording fee check should be made payable.
(g) Enter the final date that the taxpayer has to pay the bill to avoid late payment penalties.
STEP 8
The Municipal Tax Collector shall sign and date the form when the tax is paid, and if applicable, the Municipal Tax Collector shall
remit the original signed Form A-5 with the recording fee to the appropriate County Registry of Deeds. Copies of the paid, and if
applicable the recorded, Form A-5 shall be provided to the Municipal Assessing Officials for their record.
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A-5 Form Land Use Change Tax (TOWN OF ANDOVER)

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Completed 14 July 2020

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