Form Asd - 22238 - Application For Resident Business Certification Page 2

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Previously Certified Business or Purchased, Reorganized, Name Changed Business
The business is licensed to do business in New Mexico; and
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After January 1, 2012, but less than three years ago, the business obtained and was eligible for resident business certi-
q
fication. However, the business has since: (1) changed its name; (2) reorganized into one or more different legal enti-
ties; or (3) been purchased by or merged with another legal entity, but now operates in New Mexico as substantially
the same commercial enterprise;
OR
After January 1, 2012, but less than three years ago, the business applied and was eligible for resident business cer-
tification. However, before the Department was able to issue certification, the business: (1) changed its name; (2)
reorganized into one or more different legal entities; or (3) was purchased by or merged with another legal entity, but
now operates in New Mexico as substantially the same commercial enterprise.
Affidavit
SECTION III
AFFIDAVIT FROM CERTIFIED PUBLIC ACCOUNTANT
I hereby swear, under oath that it is my professional opinion that the applicant
STATE OF __________________
meets the required criteria set forth in NMSA 1978, Section 13-1-22 (B) (2012)
for Resident Business Certification and that ALL information provided and ALL
COUNTY OF ________________
checked marked statements in the foregoing application are true and complete
to the best of my knowledge.
Name
Date
State
CPA License #
Signature
NOTARY
Subscribed and sworn to before me this __________ day of _________________________, 20_________ .
(NOTARY SEAL)
Notary Public _____________________________
My Commission Expires __________________
I am authorized to sign this application on behalf of the applicant and attest to the
truthfulness of the information provided herein.
Signature of Applicant
Date
Taxation and Revenue Department
Send completed
application along
PO Box 5374
with $35.00 to:
Santa Fe, NM 87502-5374
(505) 827-0951

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