Form Rpd-41358 - Cancer Clinical Trial Tax Credit Claim Form (Page 3 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

Instructions

The purpose of the cancer clinical trial tax credit is to encour-

pathophysiology and has a therapeutic intent;

age physicians to participate as clinical trial investigators by

•

that is provided in this state as part of a scientific study

performing cancer clinical trials of new cancer treatments in

of a new therapy or intervention and is for the prevention

New Mexico and making cancer clinical trials more readily

of, prevention of reoccurrence, early detection, treat-

available to cancer patients in New Mexico.

ment or palliation of cancer in humans and in which the

scientific study includes all of the following:

To complete the form

•

1) specific goals;

Part I. Enter the information for the qualified physician, or

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2) a rationale and background for the study;

if a partnership or business association, enter the informa-

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3) criteria for patient selection;

tion for the partnership or business association, in which

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4) specific direction for administering the therapy or

the cancer clinical trials were conducted. You must provide

intervention and for monitoring patients;

the physical address of the clinic, to show where the cancer

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5) a definition of quantitative measures for determin-

clinical trials were conducted. Enter the qualified physician’s

ing treatment response;

medical license number and expiration date if the applicant

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6) methods for documenting and treating adverse

is a physician. If a partnership or business association, leave

reactions; and

these boxes blank and enter the medical license number and

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7) a reasonable expectation that the treatment will

expiration date of each owner, member or partner in Part III,

be at least as efficacious as standard cancer treat-

Section I.

ment;

•

that is being conducted with approval of at least one of

Part II. Complete this section to compute the total credit

the following:

amount allowed during the tax year. On line 1, enter the

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1) one of the federal national institutes of health;

last day of the tax year in which the cancer clinical trial was

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2) a federal national institutes of health cooperative

performed for this claim. The format to be used for the date

group or center;

is mm/dd/yyyy. On line 2, enter the number of patients who

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3) the United States Department of Defense;

participated in a qualified cancer clinical trial under the claim-

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4) the Federal Food and Drug Administration in the

ant’s supervision during the tax year of the claim. On line 3,

form of an investigational new drug application;

multiply line 2 times $1,000, but not more than $4,000 and

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5) the United States Department of Veterans Affairs;

enter the amount of tax credit that may be claimed.

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6) a qualified research entity that meets the crite-

Part III, Section 1. This section is used to identify the owners,

ria established by the federal national institutes of

members or partners eligible to claim the credit if the cancer

health for grant eligibility;

clinical trial is performed within a partnership or business as-

•

that is considered part of a cancer clinical trial;

sociation in which one or more members qualifies. For each

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that has been reviewed and approved by an institutional

owner, member or partner, enter their name, social security

review board that has an active federal-wide assurance

number, medical license number, the date their medical li-

of protection for human subjects; and

cense expires and the owner, member or partners share of

•

in which the personnel conducting the clinical trial are

the total credit allowed on line 3, Part II of this claim form.

working within their scope of practice, experience and

training and are capable of providing the clinical trial be-

Part III, Section 2. If the credit is not evenly distributed to

cause of their experience, training and volume of pa-

each member, owner or partner listed in Section 1, enter the

tients treated to maintain their expertise.

reason in Section 2.

“Rural New Mexico” means a class B county in which no

Part IV. Complete Sections 1 and 2 affirming that the cancer

municipality has a population of 60,000 or more according

clinical trial qualifies for the cancer clinical trial tax credit. You

to the most recent federal decennial census and includes

must be able to answer yes to all of the questions listed, and

the municipalities within that county. This includes areas

to provide a name and contact information for the organization

within New Mexico that are outside of Bernalillo, DeBaca.

that approved the cancer clinical trial.

Dona Ana, Los Alamos, Sandoval, San Juan, and Santa Fe

Counties.

Sign and date the claim form affirming that the information

provided is correct.

Important Definitions

“Cancer clinical trial” means a clinical trial:

•

conducted for the purposes of the prevention of or the

prevention of reoccurrence of cancer or the early detec-

tion or treatment of cancer for which no equally or more

effective standard cancer treatment exists;

•

that is not designed exclusively to test toxicity or disease

Form Rpd-41358 - Cancer Clinical Trial Tax Credit Claim Form Page 3

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