Form Rpd-41374 - 2013 Annual Report Of Non-Resident Remittees Holding An Agreement To Pay Tax On Oil And Gas Proceeds Page 2

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RPD-41374 (2013)
New Mexico Taxation and Revenue Department
*134090200*
Rev. 5/3/2013
2013 Annual Report of Non-Resident
Remittees Holding an Agreement to Pay
Tax on Oil and Gas Proceeds
- Supplemental Page -
Remitter’s FEIN or SSN
Check one:
Remitter’s name
FEIN
Page _______ of _______
SSN
Remittee’s name,
Column 2
Column 3
Column 4
Remittee’s SSN/FEIN
Remittee’s oil and
Tax withheld and
street address,
gas proceeds
paid by the remitter
city, state, ZIP code
Check one:
FEIN
Check if outside the U.S.
SSN
Check one:
FEIN
Check if outside the U.S.
SSN
Check one:
FEIN
Check if outside the U.S.
SSN
Check one:
FEIN
Check if outside the U.S.
SSN
Check one:
FEIN
Check if outside the U.S.
SSN
Check one:
FEIN
Check if outside the U.S.
SSN
Check one:
FEIN
Check if outside the U.S.
SSN
Check one:
FEIN
Check if outside the U.S.
SSN
If more space is needed, print the Supplemental page directly from
2.
Line 2. Total withholding this page.
the website and attach the additional supplemental pages to the
first page of this report. Reproducing from a photocopy reduces the
readability of the bar code on scanning equipment.
OGP-D

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