Form Rpd-41336 - Notice Of Transfer Of Land Conservation Incentives Tax Credit

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RPD-41336
State of New Mexico - Taxation and Revenue Department
Rev. 6/25/2013
Notice of Transfer of
Land Conservation Incentives Tax Credit
Purpose of this Form.
Form RPD-41336, Notice of Transfer of Land Conservation Incentives Tax Credit, must be used by a qualified intermediary
to report to the Taxation and Revenue Department (TRD) a transfer of approved land conservation incentives tax credit to
another taxpayer. This notice must be signed by the qualified intermediary and notarized. Notice must be mailed to TRD
within 10 days of a sale, exchange or other transfer. Mail to New Mexico Taxation and Revenue Department, PIT Edit Error,
P.O. Box 5418, Santa Fe, New Mexico 87504-5418. For assistance completing this form, call (505) 827-6811.
Land Conservation Incentives tax credit sold, exchanged or transferred:
Date of qualified donation:
Original credit number:
New credit number:
Amount of land conservation incentives
tax credit transferred:
Transferred from:
SSN or FEIN
Name of holder
E-mail address
Phone number
Name of contact
Transferred to:
Name of holder
SSN or FEIN
Mailing address
City, state and ZIP code
Phone number
E-mail address
Name of contact
Date of the transfer: ____________________________
Qualified Intermediary:
Name of qualified intermediary
E-mail address
Phone number
Mailing address
City, state and ZIP code
Sworn statement of qualified intermediary.
Under penalty of perjury, I declare I have met the requirements as a qualified intermediary and am reporting the transfer of
a land conservation tax credit, as set out in Section 7-2-18.10 or 7-2A-8.9 NMSA 1978. I declare that I have examined the
information and attachment and to the best of my knowledge and belief, it is true, correct and complete.
Signature of qualified intermediary
Date
Subscribed and sworn before me this
day of
, 20
Notary Public
My commission expires

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