Seller Registration Form - 2015 printable pdf download

Seller’s Registration: New Mexico Land Conservation Incentives Tax Credit 2015

Tax Credit Seller

Name(s)_______________________________________________________________________

Address_______________________________________________________________________

City/State/Zip __________________________________________________________________

Phone__________________Fax___________________Email____________________________

Social Security Number or Federal Employer Identification Number_______________________

Did the Tax Credit Seller receive the credit from a Pass Through Entity?______Yes________No

If Yes, name of Pass Through Entity__________________________________________

Type of entity

____________________________

(Corporation, Partnership, LLC, Trusts, etc.)__

Federal Employer Identification Number for Pass Through Entity___________________

Percentage of Tax Credit Seller’s ownership in Pass through Entity__________________

If you would prefer that we contact your representative:

Representative’s Name __________________________________________________________

Address______________________________________________________________________

Phone__________________Fax___________________Email___________________________

Land or Easement Recipient

Conservation Organization Name___________________________________________________

Address_______________________________________________________________________

Contact_______________________________________________________________________

Phone__________________Fax___________________Email____________________________

Qualified Appraiser

Appraiser’s Name_____________________________________________________________

Phone Number _______________________ Email__________________________________

Is your appraisal completed? ____ Yes ____ No

Value or Anticipated Value: ______________________________________________________

Land Conservation Incentives Tax Credit Process

Have you applied for a land conservation incentives tax credit through the Energy, Minerals and

Natural Resources Department (EMNRD) for your donation? ____Yes ____No

Have you submitted your Land Conservation Assessment Application to EMNRD? __Yes __No

Date /Anticipated Date of Assessment Hearing________________________________________

2919 W. 17

Avenue, Ste. 201 Longmont, CO 80503 • 303-774-8195 • fax 720-302-0447

Seller Registration Form - 2015