DELINQUENT PERSONAL PROPERTY STATEMENT
, hereby affirms under oath, pursuant to New Hampshire State Code,
that at the time the bid was submitted by (company) was / was not (please circle
one) charged with delinquent personal property taxes on the General Tax List of Personal Property for Hillsborough
County, New Hampshire.
If such charge for delinquent personal property tax exists on the General Tax List of Personal Property for
Hillsborough County, New Hampshire, the amount of such due and unpaid delinquent taxes, including due and
unpaid penalties and interest shall be set forth below. A copy of this statement shall be transmitted to the
Hillsborough County Treasurer within thirty (30) days of the date it is submitted. Ifa contract is entered into, a copy
ofthis statement shall also be incorporated into the contract between NTS and the bidder and no payment shall be
made with respect to any contract unless such statement has been so incorporated as a part thereof.
Company Signed By
Penalties *
Interest *
Total *
Delinquent Personal Property Tax *
Name & Title Date
State of
County of
SWORN TO BEFORE ME THIS
SEAL
* Mark “N/A” if not applicable
DAY OF , 20
NOTARY PUBLIC
MY COMMISSION EXPIRES
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