Form Rpd-41109 - Water Conservation Fee
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1
2RPD-41109
REV. 01/2003
STATE OF NEW MEXICO - TAXATION AND REVENUE DEPARTMENT
WATER CONSERVATION FEE
WHO MUST FILE: There is imposed on every person who operates a public water supply system a water conservation fee in
an amount equal to three cents ($0.03) per thousand gallons of water produced. A public water supply system means a system
that provides piped water to the public for human consumption and that has at least fifteen service connections or regularly services
an average of at least twenty-five individuals at least sixty days per year. A public water supply system which temporarily has
fewer than 15 service connections remains a public water supply system. If a system permanently reduces its service connections
below 15 and the system does not serve 25 or more individuals for 60 days or more, it no longer is a public water supply system.
WHEN TO FILE: The water conservation fee and Form RPD-41109, are due on or before the 25th day of the month following the
close of the reporting period in which the water was produced. When water is extracted from any surface or subsurface source
by or for a public water supply system, that water is produced for purposes of the water conservation fee. A public water supply
system produces water when another person, not a public water supply system, extracts water under contract with or as agent
for the public water supply system. Water is produced only once.
WATER CONSERVATION FEE
WATER CONSERVATION FEE
WATER CONSERVATION FEE
WATER CONSERVATION FEE
WATER CONSERVATION FEE
New Mexico CRS
New Mexico CRS
New Mexico CRS
New Mexico CRS
New Mexico CRS
0
0 0
Identification Number
Identification Number
Identification Number
Identification Number
Identification Number
REPORT PERIOD
REPORT PERIOD
REPORT PERIOD
REPORT PERIOD
REPORT PERIOD
FEIN or SSN
FEIN or SSN
FEIN or SSN
FEIN or SSN
FEIN or SSN
-
-
, , , , ,
, , , , ,
, , , , ,
1 . 1 . 1 . 1 . 1 . Total gallons
Total gallons
Total gallons
Total gallons
Total gallons
Beginning (mm-yy)
Beginning (mm-yy)
Beginning (mm-yy)
Beginning (mm-yy)
Beginning (mm-yy)
Ending (mm-yy)
Ending (mm-yy)
Ending (mm-yy)
Ending (mm-yy)
Ending (mm-yy)
subject to fee
subject to fee
subject to fee
subject to fee
subject to fee
, , , , ,
, , , , ,
2 . 2 . 2 . 2 . 2 . Line 1 divided
Line 1 divided
Line 1 divided
Line 1 divided
Line 1 divided
Check if Amended
Check if Amended
Check if Amended
Check if Amended
Check if Amended
by 1,000
by 1,000
by 1,000
by 1,000
by 1,000
, , , , ,
. . . . .
$
3 . 3 . 3 . 3 . 3 . Line 2 x .03 =
Line 2 x .03 =
Line 2 x .03 =
Line 2 x .03 =
Line 2 x .03 =
total fee due
total fee due
total fee due
total fee due
total fee due
, , , , ,
. . . . .
Please print your numbers like this:
Please print your numbers like this:
Please print your numbers like this:
Please print your numbers like this:
Please print your numbers like this:
$
8 7 6 5
3 2
0
4.
4.
4.
4.
4.
Penalty
Penalty
Penalty
Penalty
Penalty
, , , , ,
. . . . .
$
5.
5.
5.
Interest
Interest
Interest
5.
5.
Interest
Interest
, , , , ,
. . . . .
$
6.
6.
TOTAL
TOTAL
6.
6.
6.
TOTAL
TOTAL
TOTAL
RETURN BOTTOM PORTION WITH YOUR PAYMENT
RETURN BOTTOM PORTION WITH YOUR PAYMENT
RETURN BOTTOM PORTION WITH YOUR PAYMENT
RETURN BOTTOM PORTION WITH YOUR PAYMENT
RETURN BOTTOM PORTION WITH YOUR PAYMENT
WATER CONSERVATION FEE
WATER CONSERVATION FEE
New Mexico CRS
New Mexico CRS
New Mexico CRS
New Mexico CRS
New Mexico CRS
WATER CONSERVATION FEE
WATER CONSERVATION FEE
WATER CONSERVATION FEE
0
0 0
Identification Number
Identification Number
Identification Number
Identification Number
Identification Number
REPORT PERIOD
REPORT PERIOD
REPORT PERIOD
REPORT PERIOD
REPORT PERIOD
-
-
FEIN or SSN
FEIN or SSN
FEIN or SSN
FEIN or SSN
FEIN or SSN
, , , , ,
, , , , ,
, , , , ,
Beginning (mm-yy)
Beginning (mm-yy)
Ending (mm-yy)
Ending (mm-yy)
Beginning (mm-yy)
Beginning (mm-yy)
Beginning (mm-yy)
Ending (mm-yy)
Ending (mm-yy)
Ending (mm-yy)
1 . 1 . 1 . 1 . 1 . Total Gallons
Total Gallons
Total Gallons
Total Gallons
Total Gallons
subject to fee
subject to fee
subject to fee
subject to fee
subject to fee
, , , , ,
, , , , ,
Check if Amended
Check if Amended
Check if Amended
Check if Amended
Check if Amended
2 . 2 . 2 . 2 . 2 . Line 1 divided
Line 1 divided
Line 1 divided
Line 1 divided
Line 1 divided
by 1,000
by 1,000
by 1,000
by 1,000
by 1,000
, , , , ,
. . . . .
$
Name
3 . 3 . 3 . 3 . 3 . Line 2 x .03 =
Line 2 x .03 =
Line 2 x .03 =
Line 2 x .03 =
Line 2 x .03 =
total fee due
total fee due
total fee due
total fee due
total fee due
, , , , ,
. . . . .
$
Address
4.
4.
Penalty
Penalty
4.
4.
4.
Penalty
Penalty
Penalty
, , , , ,
. . . . .
$
City/State/Zip code
5.
5.
5.
5.
5.
Interest
Interest
Interest
Interest
Interest
, , , , ,
. . . . .
$
6.
6.
6.
6.
6.
TOTAL
TOTAL
TOTAL
TOTAL
TOTAL
Signature _________________________________________ Date _________________
Mail To: Taxation & Revenue Department, P.O. Box 25123, Santa Fe, NM 87504-5123
Mail To: Taxation & Revenue Department, P.O. Box 25123, Santa Fe, NM 87504-5123
Mail To: Taxation & Revenue Department, P.O. Box 25123, Santa Fe, NM 87504-5123
Mail To: Taxation & Revenue Department, P.O. Box 25123, Santa Fe, NM 87504-5123
Mail To: Taxation & Revenue Department, P.O. Box 25123, Santa Fe, NM 87504-5123
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