Form Rpd-41211 - Application For Refund Of Cigarette Tax - State Of New Mexico Taxation And Revenue Department

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STATE OF NEW MEXICO
RPD-41211
Rev. 06/2007
TAXATION AND REVENUE DEPARTMENT
APPLICATION FOR REFUND OF CIGARETTE TAX
WHO MUST FILE THIS FORM: Persons who have purchased cigarette stamps may request a refund of unused or destroyed stamps at
the price paid by the buyer. Use this form to request a refund of cigarette tax paid from the Taxation and Revenue Department. Submit
Form RPD-41211, Application For Refund of Cigarette tax and proof of destruction to Taxation and Revenue Department, Cigarette Tax
Unit, P.O. Box 25123, Santa Fe, NM 87504-5123. For assistance call (505)827-6842.
I hereby certify that:
Federal employer identification number
Buyer's name
Distributor number
New Mexico CRS identification number
Mailing address
City, state and zip code
Name of person to contact
Contact telephone number
is due a refund of cigarette tax paid for cigarette stamps unused or destroyed. The refund of cigarette
tax is requested for one or more of the following reasons:
In the line which identifies the reason for the refund request and in the
Quantity of stamps unused or destroyed
column which identifies the denomination of the stamps, indicate the
quantity of the stamps unused or destroyed and eligible for a refund. In
25 stick stamp
Cigarette stamp
20 stick stamp
the last column enter the total face value of the stamps to be refunded.
denomination
denomination
face value
1.
Cigarette tax stamps are enclosed and are uncancelled and unused.
2.
Cigarette tax stamps were affixed to packages and containers and returned
to the manufacturer. (Attach an affidavit from the manufacturer.)
3.
Cigarette tax stamps were affixed to packages and containers sold and
delivered to the United States or any agency or instrumentality thereof
(including Armed Forces base exchanges) or the state of New Mexico or any
political subdivision thereof; to the governing body or to any enrolled tribal
member licensed by the governing body of any Indian nation, tribe or pueblo
for use or sale on that reservation or pueblo grant; or sales which the state
is prohibited from taxing by a provision of the United States constitution or the
constitution of the state of New Mexico. (Attach invoices.)
4.
Cigarette tax stamps were affixed to packages and containers sold and
delivered to a point outside New Mexico for subsequent resale outside New
Mexico. (Attach invoices.)
5.
Total (In all columns, add lines 1 through 4.)
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3
6.
Enter the sum of discounts applied to the original stamp purchases.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3
Total refund (In the last column,
subtract line 6 from line 5).
NOTE: To claim a refund of unused or destroyed stamps, the stamps must be enclosed or proof of destruction
acceptable to the Department must be attached.
I declare I have examined this return, including any attached schedules or statements, and to the best of my knowledge and
belief, it is true, correct and complete.
______________________________________________________________
________________________________
Signature of taxpayer or agent
Date

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