RPD-41210
State of New Mexico
Rev. 07/2010
Taxation and Revenue Department
Gaming MFG and Distributor Tax Return
WHO IS REQUIRED TO FILE: Manufacturer or Distributor Licensees who sell, lease or transfer gaming devices in the state
are required to remit a Gaming MFG and Distributor Tax equal to ten percent (10%) of the gross receipts.
WHEN TO FILE: The Manufacturer / Distributor gaming tax is due on or before the 15th day of the month following the month
in which the taxable event occurred.
Detach the bottom portion and submit with check made payable to: New Mexico Taxation and Revenue Department. Mail to:
P.O. Box 25123, Santa Fe, NM 87504-5123. See also the instructions for this form. If you have any questions about filing
this form, please call (505) 827-0792.
MANUFACTURER
DISTRIBUTOR
1. Gross Receipts
2. Deductions
Report Month:
(mm/ccyy)
3. Tax Due
Original Return
4. Penalty
Amended Return
5. Interest
NAME:
6. Total Due
7. Total Paid
STREET/BOX:
SSN or FEIN:
CITY, STATE, ZIP:
CRS:
PLEASE CUT AND INCLUDE THE BOTTOM PORTION WITH YOUR PAYMENT
RETAIN THE UPPER PORTION FOR YOUR RECORDS
Gaming MFG/Distributor Tax
MANUFACTURER
DISTRIBUTOR
1. Gross Receipts
2. Deductions
Report Month:
(mm/ccyy)
3. Tax Due
Original Return
4. Penalty
Amended Return
5. Interest
NAME:
6. Total Due
7. Total Paid
STREET/BOX:
SSN or FEIN:
CITY, STATE, ZIP:
CRS:
GMD
Signature _____________________________ Date ______________ Phone _____________ E-mail address _______________________________