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State of New Mexico - Taxation & Revenue Department

RPD-41326

Rev. 4/4/2012

RURAL HEALTH CARE PRACTITIONER TAX CREDIT CLAIM FORM

Schedule A

Include Schedule A to Form RPD-41326, Rural Health Care Practitioner Tax Credit Claim Form, if you have unused rural

health care practitioner tax credit eligible to be carried forward from prior years.

Worksheet to calculate the total unused credit available for carry-forward from prior years

Tax year of credit approved in prior year. Enter the tax year for each credit approved for a previous tax year. Do

(a)

not enter a credit approved for the current tax year, claimed on line 2 of the first page of Form RPD-41326. Do not

enter a credit if the certificate of eligibility is for a tax year more than three years from the tax year of this claim or if

the credit was not approved by NMDOH. Unused credit may only be carried forward for three years following the tax

year for which the credit was approved.

(b)

Certification number. For each rural health care practitioner tax credit approved by NMDOH listed in column (a),

enter the certification number from the certificate of eligibility issued by NMDOH.

Amount of credit approved. For each tax credit listed, enter the amount of credit approved for the tax year.

(c)

Credit applied to prior year returns. For each credit amount listed in column (c), enter the total amount of credit

(d)

applied to prior year personal income taxes due.

Unused credit available for carry-forward. Subtract column (d) from column (c). Enter the sum of all amounts in

(e)

column (e) on line 3 of the current year claim form, RPD-41326.

A taxpayer who has both a carry-forward credit amount and a new credit amount derived from a credit approved for the cur-

rent tax year shall apply the unused credit available from the oldest approved credit first.

(b) Certification

(d) Credit applied to

(a) Tax year of credit

(e) Unused credit avail-

approved for prior year

number

prior year returns

approved

able for carry-forward

[(c) - (d)]

TOTAL Carry-forward available

Enter the sum of column (e) on line 3 on

the first page of this form.

IMPORTANT DEFINITIONS

“Eligible health care practitioner” means: (a) a certified nurse-midwife licensed by the board of nursing as a registered nurse and licensed

by the public health division of the New Mexico Department of Health to practice nurse-midwifery as a certified nurse-midwife; (b) a dentist

or dental hygienist licensed pursuant to the Dental Health Care Act; (c) an optometrist licensed pursuant to the provisions of the Optometry

Act; (d) an osteopathic physician licensed pursuant to the provisions of Chapter 61, Article 10 NMSA 1978, or an osteopathic physician

assistant licensed pursuant to the provisions of the Osteopathic Physicians’ Assistants Act; (e) a physician or physician assistant licensed

pursuant to the provisions of Chapter 61, Article 6 NMSA 1978; (f) a podiatrist licensed pursuant to the provisions of the Podiatry Act; (g)

a clinical psychologist licensed pursuant to the provisions of the Professional Psychologist Act; and (h) a registered nurse in advanced

practice who has been prepared through additional formal education as provided in Sections 61-3-23.2 through 61-3-23.4 NMSA 1978 to

function beyond the scope of practice of professional registered nursing, including certified nurse practitioners, certified registered nurse

anesthetists and clinical nurse specialists.

“Health care underserved area” means a geographic area or practice location in which it has been determined by the New Mexico

Department of Health, through the use of indices and other standards set by the New Mexico Department of Health, that sufficient health

care services are not being provided.

“Practice site” means a private practice, public health clinic, hospital, public or private nonprofit primary care clinic or other health care

service location in a health care underserved area.

“Rural” means an area or location identified by the New Mexico Department of Health as falling outside of an urban area.

Form Rpd-41326 - Rural Health Care Practitioner Tax Credit Claim Form - State Of New Mexico Taxation And Revenue Department Page 2

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