Form Rpd-41358 - Cancer Clinical Trial Tax Credit Claim Form (Page 2 of 3) in pdf

State of New Mexico - Taxation and Revenue Department

RPD-41358

Int. 07/02/2015

CANCER CLINICAL TRIAL TAX CREDIT CLAIM FORM

Page 2 of 2

Part IV - Qualifying the cancer clinical trial

The cancer clinical trial must meet all requirements in Section I, below, to qualify. Check all boxes that apply. In Section II, you must provide

the name of the organization and contact information for the entity approving the cancer clinical trial. Enter that information in Section II below.

Section I

Check all that apply:

‰

The cancer clinical trial was conducted for the purposes of:

a) the prevention of or the prevention of reoccurrence of cancer, or

b) the early detection or treatment of cancer for which no equally or more effective standard cancer treatment

exists.

‰

The clinical trial is not designed exclusively to test toxicity or disease pathophysiology and has a therapeutic intent.

‰

The clinical trial is provided in this state as part of a scientific study of a new therapy or intervention and is for the

prevention of, prevention of reoccurrence, early detection, treatment or palliation of cancer in humans and in which

the scientific study includes all of the following:

1) specific goals;

2) a rationale and background for the study;

3) criteria for patient selection;

4) specific direction for administering the therapy or intervention and for monitoring patients;

5) a definition of quantitative measures for determining treatment response;

6) methods for documenting and treating adverse reactions; and

7) a reasonable expectation that the treatment will be at least as efficacious as standard cancer treatment.

‰

The clinical trial is being conducted with approval of at least one of the following:

1) one of the federal national institutes of health;

2) a federal national institutes of health cooperative group or center;

3) the United States Department of Defense;

4) the Federal Food and Drug Administration in the form of an investigational new drug application;

5) the United States Department of Veterans Affairs; or

6) a qualified research entity that meets the criteria established by the federal national institutes of health for

grant eligibility;

‰

The clinical trial is considered part of a cancer clinical trial;

‰

The clinical trial has been reviewed and approved by an institutional review board that has an active federal-wide

assurance of protection for human subjects; and

‰

The clinical trial in which the personnel conducting the clinical trial are working within their scope of practice, experi-

ence and training and are capable of providing the clinical trial because of their experience, training and volume of

patients treated to maintain their expertise.

Section II

Enter the name and contact information for the organization approving the cancer clinical trial. Include the contact’s

name, phone number and e-mail address.

_____________________________________________________________________________________________

NOTE: Failure to attach this fully completed form to your New Mexico return will result in denial of the credit.

Under penalty of perjury I declare that I have examined this claim, and to the best of my knowledge and belief, it is

true, correct and complete.

Date

Signature of claimant

Form Rpd-41358 - Cancer Clinical Trial Tax Credit Claim Form Page 2

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