Form Rpd-41114 - E911 Services Surcharge Return
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1
2State of New Mexico
RPD-41114
Rev. 05/19/2015
Taxation and Revenue Department
E911 SERVICES SURCHARGE RETURN
WHO MUST FILE: Telecommunication companies who provide wire access lines, and commercial mobile radio service
providers who provide radio-telephone communication services by a wireless, real-time, two-way voice communication
device capable of originating a 911 call, are required to bill and to remit enhanced 911 emergency surcharge collected from
subscribers that are subject to the E911 services surcharges. Wire access lines located within New Mexico and wireless
active numbers are taxable by New Mexico. See Wireless active numbers taxable by New Mexico in the instructions.
WHEN TO FILE: The E911 services surcharge is due on or before the 25th day of the month following the month in which
the surcharge was collected. A reporting period is from the first day of the month to the last day of the month.
Make the check or money order payable to Taxation and Revenue Department. Mail only the bottom portion of this form and
the payment to New Mexico Taxation and Revenue Department, P.O. Box 25123, Santa Fe, NM 87504-5123. Retain the
top portion for your records.
For assistance call (505) 827-0762.
NOTE: When you provide a check as payment, you authorize us to use information from your check to make a one-time
electronic fund transfer from your account. When we use information from your check to make an electronic fund transfer,
funds may be withdrawn from your account as soon as the same day you make your payment.
1.
1. Qualified access lines
REPORT PERIOD:
Beginning (mm-dd-yy)
Ending (mm-dd-yy)
2. Uncollectible access lines
2.
3. Enhanced 911 surcharge
3. $
FEIN:
4. Qualified wireless active numbers
4.
CRS:
5. Uncollectible wireless active numbers
5.
NAME:
6. $
6. Wireless Enhanced 911 surcharge
7. Total surcharges
7.
$
STREET/BOX:
8. Administrative costs
8.
$
CITY, STATE, ZIP:
9. $
9. Surcharge remitted
$
10.
10. Penalty
11. $
11. Interest
12.
$
12. Total due
RETURN BOTTOM PORTION WITH YOUR PAYMENT
ENHANCED 911 SERVICES SURCHARGE
*92150200*
1. Qualified access lines
1.
2. Uncollectible access lines
2.
REPORT PERIOD:
Ending (mm-dd-yy)
3. Enhanced 911 surcharge
Beginning (mm-dd-yy)
3. $
FEIN:
4. Qualified wireless active numbers
4.
CRS:
5. Uncollectible wireless active numbers
5.
6. Wireless Enhanced 911 surcharge
6. $
NAME:
7. Total surcharges
7.
$
STREET/BOX:
$
8.
8. Administrative costs
CITY, STATE, ZIP:
9. Surcharge remitted
9. $
10. Penalty
$
10.
Check if amended
11. Interest
11. $
Signature ____________________ Phone ____________ Date ________
12. Total due
$
12.
E-mail address: __________________________________________
911
Mail to: Taxation and Revenue Department, P.O. Box 25123, Santa Fe, NM 87504-5123
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