RPD-41295
New Mexico Taxation and Revenue Department
Rev. 03/2005
Application for New Mexico Retail Food Store Certification
for the food deduction pursuant to Section 7-9-92 NMSA 1978
PART 1 - Business Information
Print the business name
CRS identification number
FEIN or SSN
Retail store information: Complete one application for each store location.
Print store name (if different from business name)
CRS identification number (if different)
chain store unit number (if applicable)
FEIN or SSN (if different)
Street address
City, state and zip code
Contact name, phone number and e-mail address
Location of records; physical address
CHECK if applicable: The retail food store described in this application is requesting eligibility for New Mexico retail store certification retroactive
to January 1, 2005. The description of this retail store operation contained within this application has been in effect since
on or before January 1, 2005.
If you are authorized to accept food stamps under the federal Food Stamp Act, you do not need to file this application and obtain
the New Mexico Retail Food Store Certificate to qualify to take the food deduction pursuant to Section 7-9-92 NMSA 1978.
Maintain your Food Stamp Program authorization in your files.
NOTE: All information submitted on this application is subject to verification by physical inspection.
PART 2 - Retail Store Operation Information
1. Type of business (Check one)
Supermarket
Nonprofit food buying co-op
(Annual gross sales $2 million or more)
Other route
Medium or small grocery
Wholesaler
Grocery/gas station
Convenience store
Military commissary
Grocery/bar
Produce stand (single store application)
Other food store
Grocery/restaurant
Multi-stall farmers’ market (application for multiple stalls)
Milk route
General store
Specialty foods - meat store, fish store, bakery, etc....
Bread route
Other combination
Health/natural food store
Produce route
2. Inventory and services sold (Check all that apply)
Check the inventory and services at this store from choices listed below:
Gasoline
Lottery Tickets
Clothing
Tobacco Products
Motor Oil
Beer/Wine
Outdoor Equipment
Other Services. What are they? (Games,
videos, pharmacy, etc....) List below. Add
Household supplies
Liquor
Hardware
page if needed. ___________________
Hot Food
Auto Parts
Food Stamp Issuance
_________________________________
3. Staple foods in inventory stock (Check all that apply)
Check the staple foods in inventory at this store from the choices listed below:
Eggs
Bread, baked goods, rice, pasta, cereal, chips,
Canned/frozen/packaged staple foods
cookies, crackers, etc.)
(including 100% juices)
Dairy Products (milk, cheese, butter, yogurt, etc.)
Fish/Seafood
Produce (fruits, vegetables)
Meat (beef, pork, lamb, etc.)
Poultry/Fowl (chicken, turkey, etc)
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